Innovations for Tackling Tuberculosis in the Time of COVID-19 Proceedings of a Workshop (2022) / Chapter Skim
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5 Financing, Ambition, and Preparedness
5 Financing, Ambition, and Preparedness
Pages 123-154
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From page 123... ...
, that explored how efforts to combat TB can be incorporated into the global health security and pandemic preparedness agenda. Panelists included John Bell, Regius Professor of Medicine at Oxford University; Bruce Gellin, chief of Global Public Health Strategy for the Rockefeller Foundation's Pandemic Prevention Institute; Rebecca Katz, professor and director of the Center for Global Health Science and Security at Georgetown University; and Michael Callahan, clinical associate physician at Massachusetts General Hospital and president of the Division of Cellular Therapeutics at United Therapeutics.
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The Global Fund and the President's Emergency Plan for AIDS Relief (PEPFAR) have created resources for low-income countries so they can address chronic endemic and
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A PLACE FOR TUBERCULOSIS IN THE PANDEMIC PREPAREDNESS AGENDA Remarks by Tharman Shanmugaratnam, Co-chair, G20 High-Level Independent Panel Tharman explored how to situate TB within the pandemic preparedness agenda. He noted that we are at an important juncture that has focused the world's attention on infectious disease threats.
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From page 126... ...
Elaborating on the lack of boundaries for infectious disease threats, he warned that the longer the pandemic spreads unchecked, the greater the risk that new COVID-19 variants will emerge. Likewise, the persistence of TB around the world coupled with improper use of drug treatments and inadequate testing is giving rise to drug-resistant TB, including multidrug-resistant TB (MDR TB)
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This work has not been adequately prioritized in the budgets of a broad range of countries for a variety of reasons. Because infectious disease threats can cross borders, containing these threats is of national, regional, and global benefit, and is therefore a global public good.
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Rather than serve as an operational entity, this global health security fund would bring forth additional resources for existing organizations. For example, such a global health threats fund could provide additional resources to the International Development Association, the Global Fund, Gavi, or any other organization working to garner support for programs that deal with both emerging and existing threats, on the condition that the organization also used funds from bilateral or philanthropic sources.
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From page 129... ...
The most efficient preparation for future pandemics relies on and reinforces the work involved in tackling endemic diseases. A new multilateral funding mechanism has the potential to strengthen multilateralism, achieve better synergy with bilateral efforts, and improve relationships between institutions to network more effectively and attack problems more seamlessly.
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How do we lift both those boats simultaneously? Tharman said in response that today's international financing of global health security -- essentially composed of efforts to prevent and combat infectious disease threats -- totals approximately $15 billion in governmental and philanthropic investments.
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Tharman held that international financing support and incentives will be needed for investments in certain global public goods even for middle-income countries. Although low-income countries will require grant money, other forms of international financing can be effective for middle-income countries.
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Sands asked for pragmatic next steps after the COVID-19 pandemic to prepare for future pandemics and to eliminate TB. Large-Scale Vaccination Infrastructure Presented by John Bell, Oxford University Bell remarked that the COVID-19 pandemic has been a challenging time for global public health, in part because of the various silos rampant within the field.
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He suggested that the TB community can contribute its extensive experience in contact tracing, community-based surveillance, and community delivery. Seasonal and pandemic influenza, TB, and COVID-19 are all respiratory pathogens, thus maintaining silos for each pathogen is not the most effective approach to addressing these diseases.4 Bolstering early warning surveillance systems during interpandemic periods can improve detection capability and provide baseline data, said Gellin.
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From page 134... ...
The purpose of the study was to use TB as a mechanism for understanding the capacity of health departments to implement physical distancing measures in a pandemic, and its findings demonstrate how capacity building for TB and PPR affect one another. Katz and colleagues have mapped budgetary data for the Global Fund onto the joint external evaluation indicators of the International Health Regulations (Boyce et al., 2021)
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Innovation in Technology and Finance Presented by Michael Callahan, Massachusetts General Hospital and United Therapeutics Noting the destabilizing effects of TB upon public health infrastructures and all-cause failures, Callahan suggested that TB would be an appropriate addition to the global health security agenda. Operational public health intervention programs for TB have been decimated by a focus on COVID19, whereas COVID-19 implementation strategies have benefited from therapy, surveillance, and other programs developed for TB.
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To address TB, Callahan commented that from a strategic standpoint, the process of addressing Mycobacterium tuberculosis should focus on avoiding selection for resistance that will decimate antimicrobial classes used for other lifesaving therapeutic purposes, notably for respiratory infections. He mentioned the potential for host modulating therapies such as DNA therapies that can temporarily disrupt large encoded biologics and enzyme systems necessary for infection or target the bacteria itself.
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Thus, understanding the bystander public health casualties is important when addressing AMR. Discussion Surveillance Systems A participant asked about the features a system would need to boost national capacity for pandemic preparedness surveillance while simultaneously benefiting people with TB symptoms presenting at primary health care clinics.
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However, the health security and pandemic preparedness space has never been measured well. Before the COVID-19 pandemic, it was difficult to raise sufficient funds to build PPR capacity owing to the lack of a compelling metric (e.g., a measure for how much safer the population would be)
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6 Would the pace at which accurate point-of-care 6 The 100-day target has been discussed as a goal for PPR in a number of initia tives including the American Pandemic Preparedness Plan and the pandemic preparedness partnership of the G7 (see https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/992762/100_Days_Mission_to_respond_to_ future_pandemic_threats__3_.pdf, accessed January 2, 2022)
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For example, an Islamic health coalition associated with the Red Crescent is focusing efforts on TB throughout Indonesia in response to the devastation TB has caused in mosques and rural communities, as well as the complexity of accessing care deemed "halal" -- or permissible -- by the Imam. Callahan suggested that capturing the attention of coalitions that are not traditional public health groups could energize the effort because these coalitions bring new targets for measurement and are able to see that TB causes business disruption, economic devastation, and bystander casualties involving other diseases.
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This raises issues around how pandemics are defined and who defines them, said Sands. Common usage of the term pandemic seems to refer to the disease death rates in wealthy countries, and this perception should be addressed in PPR efforts.
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MAKING THE CASE FOR FINANCING TUBERCULOSIS ELIMINATION Margaret Hamburg, interim vice president of Global Biological Policy and Programs for the Nuclear Threat Initiative, moderated the panel on the financing of programs and implementation of policies directed at the ultimate goal of TB elimination. In terms of a panic-to-neglect cycle, current public awareness of the threat of communicable diseases and the magnitude of health tragedies -- and social and economic dislocations -- they can cause provides an opportunity for action.
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Numerous studies have used a variety of tools to assess the economic effect of TB, including the macroeconomic implications of TB treatment and control activities. Commissioned by the Global TB Caucus in 2017, KPMG conducted an analysis on the effect of TB mortality on per capita domestic groups by projecting estimated economic losses attributable to TB-related mortality between 2015 and 2030 (Global TB Caucus, 2017)
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In contrast, meeting the SDG target by 2030 would result in an estimated 8 million deaths over the next decade and an associated economic loss of $4 trillion dollars. Meeting the SDG target by 2045 would avert an estimated 13.7 million deaths and $7.3 trillion in economic losses.
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The research provides compelling reasons for investing in the scale-up of evidence-based, patient-centered programs, including increased focus on high-burden settings, in concert with a broader global health security agenda. It also provides evidence in support of greater prioritization of investment in health by high-burden countries, said Reid.
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Although some may argue that the solution is moving TB care to the public sphere, Lomborg noted that the most realistic solution is to improve private care. The national strategic plan supported by Prime Minister Modi focuses on engagement with private care providers by offering subsidies for people to receive high-quality diagnostic tests and TB treatment in both private and public provider settings.
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This involves identifying cases in areas where people may be resistant to health care and health systems and conducting contact tracing. The process also requires diagnostics, particularly molecular diagnostics (e.g., GeneXpert platform pivoted from TB diagnostics to testing for COVID-19 in low-income countries)
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Implications for Tuberculosis from the High-Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response Amanda Glassman, Center for Global Development Glassman said that the G20 HLIP has examined the economic rationale for financing PPR and the role of subsidies at the international level, otherwise known as international financing. HLIP distinguished international financing from aid based on their purposes, and determined that international financing should be reserved for global public goods.
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HLIP acknowledged that investments in the broad set of actions needed to combat both existing and emerging infectious diseases are a contribution to global public goods, said Glassman. Initiatives addressing TB care, poverty, housing, and cash transfers could influence the trajectory of TB and of health systems overall.
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From page 150... ...
Additionally, governments tend to opt for purchasing low-quality medicine because of the decreased cost, despite the availability of higher-quality medicine through the Global Fund's pooled procurement facilities. She suggested that new funding should act in cooperation with existing funding to include incentives for using high-quality medicine.
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Dybul noted that India and countries in Southeast Asia with high TB burdens are not lowincome countries, but they have many competing priorities and treating TB in poor, marginalized populations will not boost the economy in the way that other investments might. However, COVID-19 has highlighted how quickly a pathogen can spread in urban centers.
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For instance, at the start of the COVID-19 pandemic, India received negative attention when it was unable to conduct accurate death counts, even in the country's capital. Given the possibility of a future influenza pandemic, creating a system that can use the same equipment, techniques, and metrics to address multiple respiratory pathogens could prove helpful on a number of fronts.
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She added that some governments will never prioritize response efforts, so the global health community should develop techniques to raise awareness and increase the political costs associated with failing to finance a response. Furthermore, communities working on existing diseases should view the health security agenda as an opportunity rather than as competition, she said.
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From page 154... ...
From her position on the steering committee of the InterAcademy Partnership for Science, Health, and Policy, Hamburg believes that the organization would welcome the chance to use its network of academies and regional associations of academies in identifying key priorities for action and in engaging their scientific, public health, and medical communities in this effort.10 Furthermore, Hamburg remarked that engaging the full range of stakeholders -- including academies around the world -- is important in this effort. She recalled that during her time as health commissioner in New York City in the 1990s, a resurgence of TB included unexpected and unwelcome drug resistance.
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