Moment of truth for global TB response

Moment of truth for global TB response

On Thursday 16 November 2017, Russian president Vladimir Putin told a hall full of health ministers in Moscow that TB is a “serious problem”, and said, “I am confident that the only way we can stand up against this truly global threat is if we join forces.” Over the next day and a half, the meeting at which President Putin was speaking – the first World Health Organisation (WHO) Global Ministerial Conference: Ending Tuberculosis in the Sustainable Development Era – positively resonated with such talk of the “urgency” of the TB crisis, and calls to “work together”.

Yet one of the lessons one learns when working on TB is that whether it concerns financing, health-system reform or political will, the difference between what is said and what is done is often depressingly stark. Even as President Putin was reading his speech, many people in his own country still do not have access to a state-of-the-art diagnostic test that most experts agree should be a critical part of any country’s TB response.

This gap between what is said on the international stage and what is done back home will have to close if meetings such as these are to have any impact on the actual treatment and care received by people with TB. The somewhat toothless declaration coming out of this week’s meeting may generally say the right kind of things, but governments steered clear of making any firm and binding commitments. And without firm and binding commitments, it is hard to see how such declarations can have any real impact in a world of shrinking health budgets and many competing priorities.

Even so, the process heading into the Ministerial Meeting and onward to the September 2018 United Nations (UN) High-Level Meeting (HLM) on TB presents a rare moment of political opportunity to improve the often mediocre global response to TB. There is a kind of weary optimism among people working on TB – weary because of an underlying fatalism that seems to permeate much of the TB world; optimism because at last there is a reason to hope for substantially more political will, together with all the resources that entails.

How will the BRICS fund their plans?

Together with Putin’s appearance, the establishment of a BRICS Research Network is probably the most concrete piece of good news from the meeting. Research cooperation between the BRICS (who together have around 40% of the world’s TB cases) suggests that these governments may be willing to start shouldering more responsibility and investing in domestic research capacity. It is also indirect evidence of the failure of such research cooperation processes that have come through the WHO – where wealthy countries such as the United States have managed to scupper good ideas such as a binding R&D treaty. That the BRICS nations are taking the initiative is great news.

One concern is that the deliberations behind the BRICS TB Research Network to date have been relatively insular. As a next step, the negotiators – now involving the foreign ministries of each country – should reach out to civil society, and make the work of the network as transparent as possible. One of the network’s priorities will be to “develop innovative mechanisms for R&D”, guided by “principles of affordability, efficiency, equity, and effectiveness”. Given the potential influence of industry lobbies, civil-society input may be needed to ensure these values are not lost along the way.

As with R&D more broadly, the true test of this network will be whether or not governments will put up the money. An unfunded network will offer only marginal benefits, and not the major innovations we need for TB. Extracting money from already stretched austerity budgets will be difficult, which means it will probably have to be found elsewhere. The idea of approaching the BRICS Bank was mentioned – other possibilities include sin taxes, or even financial-transaction taxes.

TB research grossly underfunded

That money for TB research is a problem is borne out by a recent report showing that total global investment in TB research was only around $726 million in 2016. The report, published by the Treatment Action Group (TAG), showed an increase over 2015 levels, but emphasised that it is still only around a third of the annual $2bn in total global investment that the WHO’s End TB Plan estimates is needed per year. For some context, the United States military budget alone is set to rise by $54 billion in 2018, to around $600 billion.

The power of TB R&D as a critical indicator, when compared to the long laundry list of issues cited in the Moscow Declaration, is that it can be measured precisely. As such, it provides probably the clearest test we have of political will. If all the world’s governments cannot even scrape together $2bn per year for a disease that kills around 1.7 million people a year, then the idealistic language of the ministerial declaration, and the declaration that will come out of next year’s UN HLM on TB, will clearly be empty rhetoric – and perhaps worse than empty rhetoric; a kind of rhetoric that loudly proclaims to help the poor, but when the time comes, does nothing.

How much should countries contribute?

While the WHO’s estimate that we need around $2bn per year for TB research is a good starting point, there are obvious differences regarding who should contribute how much. As with cutting greenhouse gas emissions, countries will differ on who is responsible for what, and on what is fair. It seems likely that a system perceived to be fair will be required if countries are to buy in or to sign up to binding funding commitments.

This problem has now been satisfactorily solved – at least in my view – by a new set of country-specific targets published by TAG. TAG suggests that each of the high-TB-burden countries and the G20 should invest 0.1% of their Gross Domestic Expenditure on R&D (GERD) in TB research. This means, by definition, that less is asked of countries that invest less in R&D, and more of countries that invest more – something that builds a degree of fairness and realism into the targets.

As with any targets, these are imperfect. It may or may not be a good idea to ask more of high-burden countries than is indicated in these targets. Perhaps there should be greater focus on increasing overall R&D spending, rather than shifting existing R&D funds to TB. When one looks at the actual targets, though, most of these criticisms fall away. Most countries will be asked to invest more (currently, only South Africa and Norway meet the targets) – but in almost all cases, the asks are realistic, given the threat and seriousness of TB. The 0.1% of GERD target also has the benefit of being simple. More complicated formulas taking into account TB burden, GDP, and GERD could be developed – but adding such complexity would make the targets more opaque.

Kicking it upstairs

In a rousing speech at the opening of the meeting, South Africa’s Minister of Health, Dr Aaron Motsoaledi, said: “We must come up with innovative research and development models, such as The Life Prize – formerly known as the ‘3P’ project – which delinks the cost of R&D from the final cost of medicines.” It was disappointing that, apart from strong interventions by Motsoaledi and South Africa’s Director General of Health, Precious Matsoso, The Life Prize and delinkage did not get more traction at the conference – given that The Life Prize (in its specificity) and delinkage (with its intellectual framework) are some of the best responses we have to the partial market failure of TB medicines and diagnostics, where patent protection has proven insufficient incentive to drive innovation. In his understanding of how increased R&D can best play out in the real world, Motsoaledi was a step ahead of most other speakers.

He was also clearer than most about the politics of the process, heading toward the UN HLM. He was unequivocal that heads of states must now take responsibility, and give ministers their “marching orders” in the fight against TB. He is correct.

At the opening of the ministerial meeting, President Putin said: “Another important success factor is to step up scientific tuberculosis research and develop effective diagnostic tools, vaccines and medicines, including those aimed at treating resistant forms of tuberculosis. In this regard, I believe that the initiative of the BRICS countries to create a network to study tuberculosis is very important.”

No doubt many similar things will be said by other world leaders in the next 10 months, and at the 2018 UN HLM on TB. Yet, behind the words, hard cash and hard indicators such as investment in R&D will tell us whether our world leaders mean what they say; whether President Putin is serious about TB; whether the emperor is wearing any clothes.

Note: Low is a member of the Life Prize steering committee. The Life Prize is mentioned in this article. Low’s views are his own.

Note: This is an early online access article from the upcoming print edition of Spotlight to be launched on 1 December 2017.