TAC survey highlights poor infection control in clinics

By Marcus Low

Tuberculosis (TB) infection control measures in some South African public sector clinics fall woefully short. This is according to an infection control survey that was published by the Treatment Action Campaign (TAC) ahead of World TB Day (23 March 2017).

While the survey has some limitations, and is by no means an exhaustive survey of clinics in South Africa, it nevertheless provides compelling evidence that we have an infection control problem at a number of public sector clinics. Given that poor infection control at clinics may be a significant contributor to TB transmission in South Africa, this is a red flag that should be taken seriously.

How was the survey conducted?

TAC branch members across seven of South Africa’s nine provinces were trained on a TB infection control questionnaire. Delegations from TAC branches then went to their local clinics to fill in the questionnaire. They reported their findings back to the TAC national office where the findings were captured.

The questionnaire contained seven questions relating to TB infection control measures that should be in place at clinics. Each question was simply given a “yes” or “no” answer. It was designed in such a way that “yes” answers in each case indicated correct infection control procedures. In other words, the more “yes” answers a clinic got, the better.

What did the survey find?

As part of their media release, TAC published an Excel file with the data they collected. This file contains details of the 158 clinics that were surveyed and how each of seven questions were answered in relation to these clinics. Below we present some additional analysis we conducted of the data provided by TAC. (For those interested in exploring the data, we have done some data cleaning and saved it as a CSV file that can be downloaded here.)

While TAC rated each clinic red, orange, or green – the data can also be represented as a score out of 7 for each clinic – where each yes answer adds 1 point to the score. Thus clinics that score 7/7 are rated green, 5/7 or 6/7 are rated orange, and 4/7 or less are rated red.

Scores by province

ProvinceNumber of clinics surveyedMean score out of 7
Western Cape 15 4.67
KZN20
3.85
Eastern Cape253.52
Free State193.16
Limpopo233.0
Mpumalanga392.92
Gauteng172.88

The above table shows the mean score of the clinics surveyed in each province. We should stress though that these are not representative samples and the findings cannot be generalised to entire provinces. The mean scores in some provinces are also so close together that we should not read anything into the fact that e.g. Mpumalanga is above Gauteng, or that Free State is above Limpopo. It does seem significant however that the clinics that were surveyed in the Western Cape tended to do substantially better than clinics surveyed in other provinces.

No clinics in the North West province and the Northern Cape were surveyed. Of the seven provinces surveyed, Mpumalanga is somewhat over-represented with 39 out of the 158 clinics – most other provinces had around 20 clinics surveyed.

Results by question

This table shows the total NO and YES answers to the seven questions. In each case YES indicates correct infection control measures. Only question 1 and 3 received more than 50% YES answers. Question 5 received exactly 50% YES answers.

QuestionsAnswered NOAnswered YES
1. Are the windows open?22136
2. Is there enough room in the waiting area?9266
3. Are there posters telling you to cover your mouth when coughing or sneezing?6494
4. Are you seen within 30 minutes of arriving at the clinic?10157
5. Are people in the clinic waiting area asked if they have TB symptoms? 7979
6. Are people who are coughing separated from those who are not?10553
7. Are people who cough a lot or who may have TB given tissues or TB masks?11642

The TB infection control measure on which clinics did the best was keeping the windows open in the waiting area. Second best was having posters up on the walls telling people to cover their mouths when coughing or sneezing. However, apart from opening windows and having posters on the walls most clinics did very poorly at TB infection control.

It is also notable that on the cross-cutting question as to whether people are seen within 30 minutes, only 57 of the 158 clinics got “yes” answers. Long waiting times becomes a more important risk factor when other infection control measures are not in place because people are exposed for longer periods. The mean score in clinics with less than 30-minute waiting times was 5.1 compared to only 2.3 in clinics with longer waiting times – in other words, the clinics where people waited longer tended to be clinics where the risk of TB infection were already substantially higher.

How much did clinic scores vary?

Only 15 of the 158 clinics in the survey got “green” ratings. 31 were rated “orange” and 112 were rated “red”. The mean rating for all clinics surveyed was 3.34/7 and the median was 3/7.

Measuring up to the task of tackling HIV and TB in the new NSP

By Julia Hill

What gets measured gets done and, ideally, gets improved. As the South African National AIDS Council (SANAC) nears completion of the next National Strategic Plan (NSP) on HIV, TB, and STIs (2017-2022), lofty ambitions for positive outcomes are in place. However, what provinces and districts are expected to measure in order to track implementation and incremental steps toward these goals is—at this point—completely absent from the NSP.

Correctly, the NSP aims to achieve substantial reductions in HIV infections to fewer than 100,000 per annum by 2022, and reach UNAIDS 90-90-90 targets by 2020 for HIV testing, retention in care, and viral suppression. Biomedical and social service approaches to HIV prevention are also prominent, including tackling the national epidemic of sexual violence. On the TB front, the NSP similarly seeks to close the gaps in prevention, diagnosis, treatment initiation, and treatment success, and specifically notes the special attention that must be paid toward bringing the drug-resistant TB (DR-TB) epidemic under control.[i] The wish-list of goals in the NSP leaves out very little. But these targets are expected outcomes—and outcomes do not evolve from a programmatic void.

The resulting pie-in-the-sky document makes it difficult for communities most affected by HIV and TB to hold to account AIDS Council governance structures and government departments. National success depends on smaller programmatic successes at district, sub-district, and service provision level. Monitoring and evaluation (M&E) standards must therefore be put in place at these system levels to ensure people are able to access services intended to lead to achievement.

For example, the intention to put half a million adolescents on PrEP by 2022 is overdue and welcome. But where is the breakdown for what districts are expected to contribute to that national total? High-burden districts like King Cetshwayo (formerly uThungulu) in KwaZulu-Natal have HIV incidence rates among adolescent girls that skyrocket to 6.2% by age 19[ii] –far exceeding the WHO threshold for PrEP eligibility. These districts should have very specific targets for the number of adolescents that should start and be retained on PrEP. But districts and sub-districts should also have ambitious targets in place for the proportion of schools offering HIV testing services and referrals to preventative services such as PrEP, or for the proportion of facilities implementing youth-friendly services—such as staying open after-hours on some days of the week. It is through monitoring these types of indicators that we can ensure that districts are offering services that put them on track to meet targets.

At the 21 February 2017 consultation on Draft 1 of the NSP, interested parties were invited to participate in shaping indicators and targets for the provincial implementation plans. A long list of possible indicators was shared with this group. Some indicators were intended to be aggregated at the national level to measure major outcomes—such as the number of people on antiretroviral therapy—but a number of process indicators were also proposed that, if well-designed, could be used to measure programmatic implementation progress down to the sub-district level.

It was not clear if provinces were required to report on any of these process indicators, or if they are merely expected to select those they find interesting or convenient. Outcomes of this meeting were—to our knowledge—never published online or shared, making it extremely difficult for provinces to incorporate programmes and M&E support into their implementation plans.

However, it is not too late for provinces and high-burden districts to be offered guidance on what to prioritize. Not everything must be done everywhere, but certainly a bare minimum must be universally required across the country, and high-burden districts must be required to implement additional interventions beyond the minimum.

So what type of interventions should be prioritized as the essential minimum required from all districts, and implemented with urgency in high-burden districts? At Doctors Without Borders (MSF), our short-list includes the following:

  • Proportion of sub-districts offering a package of school-based services (including HIV testing, TB and STI screening, pregnancy tests, condoms, and referrals for PrEP, VMMC, and referral to further HIV/TB services) in 100% of schools – Target 80% of sub-districts by 2019; ≥90% by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of PrEP courses distributed to adolescents and youth – National target of 200 000 adolescents and 75 000 women age 20-24 initiated on PrEP by 2019; 500 000 adolescents and 200 000 women age 20-24 by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of free HIV self-testing kits distributed in public sector – National target of 3 million tests per year by 2019; 10 million per year by 2022
  • Proportion of sub-districts with primary health care (PHC) facilities (including community health centres (CHC)) offering essential services for sexual violence survivors (forensic examination, PEP, emergency contraception, psychological counseling, social assessment), linked into interdepartmental referral network for more advanced services – Target 100% of designated PEP facilities in all HIV high-burden sub-districts capacitated by 2020; 100% of all sub-districts with minimum one facility by 2022
  • Proportion of CHC/district hospitals and PHC facilities in high-burden settings providing comprehensive DR-TB services (diagnosis, treatment initiation, continued management –Target 100% of PHC facilities in high-burden settings; target minimum one facility per sub-district in lower-burden settings. Total of 800 facilities by 2019; total of 1000 facilities by 2022.
  • Proportion of PHC facilities not providing 3-month ART refills to stable ART patients – Target <5% of facilities by 2019; 0% of facilities by 2022.
  • Proportion of PHC facilities per sub-district achieving ratio of one lay health worker: 800 people within community (with 25% of lay workers facility-based; 75% community-based – Target 80% of facilities by 2019; 100% by 2022.
  • Proportion of treatment sites (including community pick-up points serviced by Central Chronic Medicine Dispensing and Distribution) experiencing stock outs of ARV or TB meds –  Target: <10% by 2019; <5% by 2022.
  • Proportion of PHC facilities in HIV high-burden districts and CHC in all districts offering after-hours/Saturday services for ART initiation and/or ART refill collection – Target 75% by 2019; 90% by 2022.

This approach will require strengthening data capturing and M&E systems, and the public must have access to data if those responsible for action are to be held to account. It is mandatory to invest in requiring and measuring programmes if we are to avoid frittering away the next five years. When sub-districts receive specific guidance, they are inclined to implement it—this is evident in the massive uptick in numbers enrolled on HIV treatment, or registered to receive their medicines at community pick-up points. And if government departments or other stakeholders do not implement programmes, or do not run them well, then a robust M&E system makes it obvious where intensified efforts should be directed to improve the quality and availability of HIV and TB services.

South Africa knows what it wants to accomplish in reducing the national burden of HIV and TB over the next five years. The major question remaining is whether or not it will measure up to the task before it.

Julia Hill is Deputy Head of Mission, Doctors Without Borders/Médecins Sans Frontières South Africa

[i] SANAC. Draft 2: South African National Strategic Plan on HIV, TB and STIs 2017-2022. Accessed 27 March 2017. Available at: http://sanac.org.za/wp-content/uploads/2017/03/NSP-Draft-2_24-February-2017.pdf

[ii] Grebe E, Huerga H, van Cutsem G, Welte A. (2016) “Cross-sectionally estimated age-specific HIV incidence among young women in a rural district of KwaZulu-Natal, South Africa” presented at the 21st International AIDS Conference. July 18-22 (2016), Durban, South Africa.

The Achilles Heel of the new NSP: Accountability and Equity

By Russell Rensburg

As we move towards the release of South Africa’s latest National Strategic Plan for HIV/AIDS, TB and STI’s it is important to celebrate the successes achieved since the end of AIDS denialism and the introduction of a revitalised AIDS response in 2006. Getting there and sustaining the response has required significant political will and herculean effort to harness the combined energy of all sectors. The results are undeniable: we have seen over 3 million people initiated on treatment (something almost inconceivable at the start of the journey), the near elimination of mother to child transmission.

Successes aside, significant challenges remain: our performance on TB is less than spectacular and the rate of new infections among key populations—such as young woman, men who have sex with men and commercial sex workers—remains unacceptably high.  We are almost there, but not quite.

The new NSP, which is deeply rooted in the global AIDS movement, heralds the end of AIDS by 2030. This belief is premised on the 90 90 90 strategy, which a lot like the offside rule in football, is deceptively simple but often difficult to explain. All things considered, the goal is to test 90 % of people, initiate 90% of those who test positive on treatment, and ensure that at least 90 % of those on treatment have suppressed viral loads, which will lower the risks of HIV transmission and prevent new infections. The idea is well articulated in the new NSP which proposes several innovative strategies to realise these goals. Some strategies target key populations, those directed at young women and girls, and strategies aimed at high transmission districts.

So, we have a good plan in hand? Not quite, we are afraid.

What makes a good plan is a plan that promotes equity and a plan that is informed by the people most affected. A good plan is a plan that we know will be implemented due to robust accountability mechanisms. These in our view are the Achilles’ heels of the new NSP.

Community consultation

There are complaints from different sectors as to the integrity of the consultation process. As with our own submission, there are allegations that the input of critical stakeholders, most especially community groups, have not been taken sufficiently into account. It would strengthen the plan’s standing if it could make fully transparent the consultation process and how key concerns have been addressed; or if not, why not.

Crumbling rural Building Blocks

Our second major concern regards the feasibility of the plan. Don’t get us wrong, we  am not advocating for a less ambitious plan – but for a realistic, equitable plan.  The World Health Organisation in their framework for strengthening health systems identifies six building blocks that are essential to a truly functional health system. These building blocks include leadership, human resources for health, service delivery platforms, sustainable financing, medical technologies and health information system. Looking at the plan through this lens, the feasibility of the new strategic plan is indeed exposed. To illustrate the challenge that lies ahead, it may be useful to reflect on a few of these concerning the goals presented in the NSP.

For instance, the NSP recommends a rapid expansion of the country’s treatment program by focusing on high-risk groups with the hope to more than double the number of people on treatment. Logically, it follows that the expansion in treatment will require concurrent investment in improving the functionality of the district health system. The reality, however, is that the NSP kicks off at a time when resources for health are diminishing, a weak currency is contributing to significant increases in drug prices, and there is a deepening crisis in human resources because resources are insufficient to meet basic HR needs. The system is close to collapse.

The picture is particularly bleak in rural areas where more than 40% of our population currently reside. Rural facilities, which have always struggled to attract health professionals, are further threatened by staffing moratoria. Infrastructure problems and neglect and the lack of investment in dignified and family-friendly accommodation for rural health care workers are other disenablers for the recruitment and retention of health care workers so critical to implementation of the NSP in the rural areas. Investment in HR is being channelled to larger urban centres, placing at risk millions of rural woman and girls who continued to be left behind.

The Role of SANAC

This brings us to the very critical role of the South African National AIDS Council (SANAC). Against the above context, it is obvious that SANAC needs to ensure that the NSP speaks to these rural realities for if not, it is a plan doomed to fail on Government’s mandate to plan and deliver for all who live in South Africa. Secondly, SANAC ought to advocate robustly for these rural realities to be turned around: for strong, firm building blocks to be put in place and for these to be protected in rural South Africa. Beyond more nurses, doctors and pharmacists in rural areas, what we need are sufficient community health workers to reach the most impoverished communities at household level; and Clinical Associates to upscale the Medical Male Circumcision drive and to support the minimal numbers of doctors in many small rural hospitals at the brink of collapse.

While the NSP continues to advocate for a multi-sectoral response that includes all stakeholders, it provides little guidance on how the various sectors will interact nor does it provide an accountability framework against which the custodians of SANAC can be assessed. This is particularly important when you consider that beyond the development of the NSP, SANAC has little influence on how the strategy is implemented. What is required is a strong SANAC that has the support of all stakeholders. A strong SANAC that can lead, direct and accelerate the response. We fear SANAC in its current state does not meet this muster.

To ensure the success of this NSP urgent attention to the governance and accountability frameworks are needed. As a start, the current leadership vacuum has to be addressed. Secondly, there should be a robust review of existing governance structures at national provincial and district levels. Finally, it is time for fresh elections of all SANAC office bearers, ensuring that we have the right people in place with the courage and commitment to coordinate and oversee the implementation of an equitable NSP that brings quality HIV and TB services to all.

Russell Rensburg – RHAP Programme Manager: Health Systems and Policy

Prisons and the New NSP: Nobody left behind?

by  Ariane Nevin[1] and Thulani Ndlovu[2]

Evidence has shown that prisons are a key battleground in the fight against HIV and TB. Prison populations are transient, and inmates are released back into their communities, taking with them all of the infections and unhealthy behaviours learned in prison. This means that any HIV and TB plan that doesn’t address the drivers of HIV and TB in prisons will fall woefully short of achieving its goals. And sadly, the latest draft of the NSP, with its inadequate prison-focused interventions, looks set to do just that.

The first draft of the NSP, released in November 2016, was cause for some jubilation for prisoners’ rights activists, for the first time including inmates as an HIV key population and incorporating important human rights language and interventions for prisons. However, we may have celebrated too soon, as two drafts later, following a far from transparent or inclusive political process, the prison-focused language has been markedly stripped down.

Although inmates remain a key population for both HIV and TB, and recipients of a core package of services targeting key populations, the NSP is missing interventions directed at addressing the causes of the TB and HIV epidemics in prisons: insufficient infection control, non-implementation of the Policy to Prevent Sexual Abuse of Inmates, dismal levels of overcrowding , inadequate ventilation, and insufficient re-integration support or linkage to care for ex-inmates upon release, to list but a few.

The latest draft includes as an objective, ‘Train correctional and detention centre staff regarding the prevention and health care needs and human rights of detainees and inmates living with or at risk of HIV and TB.’ However, sexual violence and overcrowding in prisons, which are key drivers of HIV and TB respectively, do not feature in any objectives. Surely any plan directed at training correctional centre staff on the prevention of HIV should look first to existing policies, of which the Policy to Prevent Sexual Abuse of Inmates is an excellent one. Why not include the implementation of this policy as an objective? Likewise, if we are to reduce TB infection rates, the plan should at the very least include amongst its objectives a strategy to reduce overcrowding.

The Departments of Correctional Services and Health receive plenty of money to fund their TB and HIV response, which they are using to test and screen inmates. However, they can counsel and screen as much as they like; until plans are developed and fully implemented to address the drivers of the epidemics, attempts to contain and beat them back will continue to have minimal impact.

International donors need to push DCS for a more comprehensive approach, greater transparency and better data. We cannot continue simply to roll out treatment blindly. If we are going to win this fight, we need to cut off these diseases at the knees.

Inmates and ex-inmates would have been the most qualified to suggest effective strategies for preventing TB and HIV in prisons, and effective support for reintegration of ex-inmates into their communities. However,  the inclusion of key populations in NSP consultations was made difficult, if not impossible by SANAC’s dismal organisation and planning that left important participants stranded and ultimately not consulted. Not only this, but the processes through which provisions are included or left out was entirely opaque, leaving stakeholders frustrated and in the dark, and SANAC, unaccountable.

So, what should the targets be?

  • Full implementation of the DCS Policy to Prevent Sexual Abuse of Inmates in DCS Facilities: Sexual abuse is prevalent in prisons, and is a recognised driver of the spread of HIV inside prisons. Unless urgent steps are taken to detect, prevent and respond to sexual violence in prison, transmission of HIV will continue.
  • Full implementation of a TB infection control policy: Prevention is better than cure and raising awareness among inmates that windows should be left open is not adequate. Steps need to be taken to decrease overcrowding, to ensure that cells have sufficient cross-ventilation and to allow inmates to spend more time spent outside of their cells. The NSP must set more concrete targets in this regard.
  • Urgent steps need to be taken to address extreme overcrowding in prisons: TB and HIV infection control policies will continue to have limited impact until overcrowding is decreased. Studies show that implementation of national cell occupancy recommendations could reduce TB transmission risk by 30%. The NSP must set concrete and measurable targets in this regard and map out a clear and workable strategy to eliminate overcrowding as soon as possible.
  • An effective prison oversight body with sufficient independence and powers to investigate and refer complaints needs to be established to replace the Judicial Inspectorate for Correctional Services: this will ensure that DCS policies are adhered to, and their obligations met. It will also provide a safe avenue through which inmates may submit complaints. Improved linkage to care between prisons and communities, and support groups for ex-inmates: Inmates need to receive counseling, a copy of their medical file and a referral to a clinic accessible to their community to enable adherence to treatment once they leave prison. They also need ongoing support to avoid re-offending. These services are currently lacking. In order for this to happen simple systems need to be put in place, and the DCS, DOH and DSD need to work together to ensure that there is no loss to care in the transition between incarceration and freedom.
  • An effective collaboration in real time between the DCS and NDOH to ensure that new NSP policies, like Universal Test and Treat and condom distribution are implemented with no delay.

We hope that the final NSP 2017-2022 will take heed of this advice, and look forward to an NSP that is actually strategic and truly leaves nobody behind.

[1] Sonke Gender Justice

[2] Zonk’izizwe Odds Development

Towards a workable plan

By Vuyokazi Gonyela, SECTION27

A key ingredient to ensuring our response to the AIDS and TB epidemics is effective, is having a workable plan. To that end, consultants and experts are working furiously to make sure South Africa has a new National Strategic Plan (NSP) to take us through to 2022.

But we know what is said about South Africa and our plans and policies: Full marks for great plans and policies; fail for implementation. The involvement of civil society is a critical component of a

The involvement of civil society is a critical component of a workable plan.
The involvement of civil society is a critical component of a workable plan.

workable plan. Established civil society structures already exist within the various AIDS councils at national, provincial and municipal (local or community) level but there is an unequal distribution of resources from the councils to these structures, which, in turn, means they struggle to get work done and to participate meaningfully in processes.

South Africa’s response to the HIV/AIDS, TB and Sexually Transmitted Infections (STI) epidemics requires coordination and leadership from various accountability structures, including the South African National AIDS Council (SANAC). This body hosts the National Civil Society Forum (CSF), which monitors progress on the implementation of the NSP and holds government accountable on behalf of the users and practitioners in the health-care system.

Theoretically, national structures that manage the HIV/AIDS TB and STI response should function in a manner that provides both leadership and support to provincial and local structures. But, provincial and local bodies need to be just as empowered to hold the government accountable – even more so – on behalf of the health-care users on the ground.

Despite this theoretical commitment to the development and strengthening of provincial structures, little has been done to provide these structures with the resources and authority that they need.

In provinces like the Eastern Cape, the struggles and difficulties are clearly visible. The province has struggled to implement strategies to respond to HIV/AIDS, which has left the community at a great disadvantage. Among the factors that impact negatively on the work to be done, is poor leadership. In the Eastern Cape, for example, the former elected CSF chairperson was last seen in 2015. This critical position was left unattended because the leader had other interests that compromised, not only the forum, but the entire provincial mandate.

The intervention campaign and strategies also need to adapt and respond to new data. Recent statistics indicate that the prevalence of HIV/AIDS has shifted from adolescents to young women and girls: the stats show about 2,363 new infections weekly in South Africa, with AYWG accounting for almost 1,750 of these infections.

The goal to end HIV/AIDS by 2030 is far from being realised, particularly because there is little investment in developing young leaders and creating more active citizens. They have a big role to pay and are central in our response to HIV if we truly want to deliver on the rhetoric of ending AIDS.

A further concern is that women are grossly under-represented within provincial leadership sectors tackling HIV. Across the nine provinces, the leadership is mainly dominated by men. Provincial CSF chairpersons sit on the Provincial Councils on AIDS as co-chairpersons; seven of the nine provincial chairs are male. The Eastern Cape took a bold stand in September 2016 and elected the first woman as a CSF chairperson. No attention is paid to this.

The voices of many women are suppressed in their households, communities and in leadership structures. Provincial AIDS structures need to take the lead, transform themselves, and support capacity-building female leadership as a critical investment, not only for the provinces but for the country. Nothing less will do.

Communities in crisis

By Treatment Action Campaign

The Treatment Action Campaign has shared the following stories with Spotlight from their provincial operations in KwaZulu-Natal, Limpopo, Mpumalanga and the Free State. Elsewhere in this issue of Spotlight we take an in-depth look at Gauteng – which is therefore not included here.

France, KwaZulu-Natal

france-kzn1
Branch members go door to door in France to find out how people in the community cope without a clinic.

The community of France in KwaZulu-Natal does not have a clinic. A mobile clinic comes to the community just once a month. But most people don’t use it; some don’t even know about it. Instead they travel by taxi to other clinics – if they can find the money. Sometimes they must lie about where they live in order to see a nurse, or they simply go without medicines and health services altogether. Only certain community caregivers can deliver medicines to patients, if they have an ID, and if the patient is being treated at the mobile clinic. The rest, however ill, have to collect medicines themselves. It seems people are defaulting on ARVs, TB treatment and other chronic medicines as a result. We can never have #treatment4all – or #EndTB – when people can’t even get to the clinic. TAC members have asked the people of France how only having a mobile clinic affects them. The resounding response is that once a month is not enough. To resolve service deficiencies such as this one, which keep the dual epidemics burning, health system challenges must be addressed in the National Health Department’s test-and-treat plan and within the new National Strategic Plan on HIV, TB and STIs. Otherwise we are doomed.  #FranceNeedsAClinic.

Khujwana, Limpopo

Within a few hours of walking door to door through the streets of Khujwana it is clear there is a major problem. Every home has a story to tell – a story of frustration and suffering, a story of failure.

While the local clinic looks functional, even ‘pleasant’, from the outside with its solid infrastructure and garden, inside it s a totally different matter. Many patients report ongoing stockouts and shortages of their medicines. They wait for hours before being seen by anyone – there is a shortage of nurses and no doctors ever come. Some go to other clinics altogether. People report incidences of nurses treating them badly, being rude or, worse, negligent. Mothers report the indignity of having been mistreated, or unattended to, in the midst of labour. Khujwana Clinic is failing the people and the community it is meant to serve. Tired of this situation, the community is mobilising. Testimonies from community members who try to use the clinic are being gathered. Local stakeholders are coming together to draw attention to the major shortcomings. All they want is a clinic that can give them the health-care services they need. They are clear: They will continue to escalate this issue until they #FixKhujwanaClinic.

Boekenhouthoek, Mpumalanga

The local TAC branch in Boekenhouthoek receives ongoing complaints about the local clinic. People

In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.
In Boekhouthoek a TAC branch member takes testimony from a community member struggling to access health services.

report waiting for long periods of time, with or without being seen. There aren’t enough nurses stationed in the clinic exacerbating this issue. The clinic is too small, and people wait outside while waiting to be seen. The clinic is faced with regular stockouts and shortages of medicines meaning people are often sent home empty handed. Some community members choose to go to different clinics altogether. A luxury that many of those unemployed people who live in the area cannot afford. Traditional leaders confirm these conditions, from personal experience. One woman spoke of never receiving a TB diagnosis, months after taking a test. One man spoke of misdiagnosis. Another had never been told he had HIV, yet had been prescribed ARVs for more than four years with serious side effects. People reported of nurses being rude to them in moments of severe vulnerability. The TAC Boekenhouthoek branch is monitoring the clinic and gathering information from residents about the challenges they face. How can we reach #treatment4all if clinics run out of medicines? Or if people don’t want to use them because of the lengthy waits and poor service? The reality is that the dysfunction in our health-care system will stop the new HIV guidelines on test-and-treat from being a success. We need significant investment into stronger systems in order to respond to the HIV and TB epidemics. #BetterBoekenClinic

Phuthaditjhaba, Free State

Members of the TAC in Phuthaditjhaba have reported serious problems at Manapo Hospital that are putting people’s right to access health care in serious jeopardy. This report followed a strike by frustrated, overburdened staff members, including doctors, nurses, physiotherapists, porters, cleaners, and kitchen staff, who claimed to have not received pay for significant amounts of overtime since 2015. TAC members investigated the hospital and spoke to many patients entering and exiting the facility. Reports of long waiting times, a lack of nurses, doctors, and other staff being stretched beyond their capacity, and medicine shortages, were common.

After being stabbed in the forehead, one teenager reported not seeing a doctor after seven days of waiting. Another teenager had been stabbed in the upper chest four days earlier. He was also still waiting to see a doctor. A woman with a homemade sling and swollen wrist left the hospital in pain to return to the clinic. One man, falling in and out of consciousness, was told to return to casualty with a referral letter. Outside the hospital, visibly injured patients could be seen wandering the grounds in their pyjamas. After taking a rest on the grass, one young man with bandages across his face struggled to stand up and had to be assisted by two other patients to get onto his feet before limping back inside. Portable toilets remain outside the hospital after a water crisis the month before. It is unclear whether the water shortages continue. A TAC member helped a man with crutches who struggled to climb up the metal steps to enter the toilet. If urgent action is not taken to turn around this crisis, the TAC will be forced yet again to embark on a campaign of civil disobedience in order to save the lives of those reliant on the failing public health-care system. #FSHealthCrisis

 

 

 

 

Rich province, poor health care

By Ufrieda Ho

In money terms, Gauteng’s health budget looks plump and healthy at R37,4 billion for the 2016-2017 financial year – R2.07 billion more than the previous financial year. It represents a sizeable portion of the province’s overall budget. On the surface, this is money that could make a significant contribution to improving the health outcomes for the province’s patients.

But, even though it’s South Africa’s richest province, Gauteng is under pressure from a growing metropolis and is not future-proofing fast enough for its evolving needs. There are challenges of rapid urbanisation, with high migrant numbers and community members who are transient and difficult to track medically. The province also has to plan for accelerated environmental degradation, overcrowding, job shortages, limited resources and the yawning gap between the haves and have-nots.

The divisions are evident in data from Stats SA’s General Household Survey of 2015, which was released in June this year. For example, Gauteng is home to the highest percentage of medical aid members in the country at 27.7 percent, but this still leaves 70 percent of the population reliant on that R37,4 billion to be spend wisely and effectively.

The Gauteng Department of Health has its own hurdles to overcome, including proving that it is fit to govern. After being placed under administration in 2013, the department finally achieved an unqualified audit from the Auditor General for its financial management this year.

But the health issues continue to be a challenge in the province. On-going staff shortages, overworked staff, unreliable ambulance services, staff who don’t treat patients with dignity, and a disconnect between policy and plans and the reality on the ground. Increasingly, bureaucracy replaces communication, and there are more reference numbers and records of complaint than actual solutions or firm plans on how problems can be rectified.

In addition, a tangled web of social failings impact on the health-care challenges. There’s high unemployment and competition for scarce resources. Public works shortfalls mean infrastructure in hospitals and clinics is not upgraded or maintained. And the high cost of commuting, or lack of proper roads in new developments, represent very real barriers to accessing health care for many patients. The protracted drought in southern Africa has also made food security a great cause for concern among the most vulnerable people in the province.

It is a most distressing trend that already weak health-care standards are slipping further and that there are clear losses in areas where gains had previously been achieved. For Gauteng TAC leaders Portia Serote and Sibongile Tshabalala, these include noticeable deterioration in the way TB is being managed in many of the province’s clinics and hospitals.

Serote, who works mainly in the East Rand districts, says many basic good care and oversight practices are simply not adhered to.

‛We can walk into clinics and see people not using masks. Patients are all mixed up in the same small facilities – so you can see XDR and MDR patients with TB patients. There is no infection control, or the UV lights (that help limit the spread of infection) are not working,’ says Serote.

She says the TAC has had to step up its own outreach programmes after discovering in a spot sampling exercise recently, that out of 60 people, 10 had TB and three had MDR-TB.

Another growing concern, says Tshabalala, is the high number of ARV defaulters that they are noticing. Tshabalala says the target of getting patients to undetectable viral loads is slipping.

‛We did a workshop and survey in Orange Farm earlier this year and found that people default because they can’t afford the taxi fare to get to a clinic, and it’s too far to walk. They also have to wake up by 4 am to get to a clinic or hospital if they want to get help that day. There is a benchmark for waiting of 180 minutes, which is just too long,’ says Tshabalala.

The facilities that people rely on have no privacy, are often cramped and have not been properly maintained. Serote says she’s visited clinics where nurses have brought curtains from their homes so patients can have some privacy and dignity during their consultations.

And, Serote says, mental health patients are falling through the cracks in the province. The TAC has seen an increase in the number of patients who simply walk out of hospitals in hospital pyjamas, completely unnoticed, sometimes for days.

‛The nurses were just unaware in Pholosong in Tsakane, when a man who was mentally ill just got up from his hospital bed and left. He was living in really terrible conditions and that’s where we found him, still in his hospital clothes, but the nurses didn’t know anything,’ she says.

Both Serote and Tshabalala acknowledge the nurses are under immense pressure themselves. ‛Nurses are not just nurses; they are counsellors, they’re cleaners – they are expected to do everything. The Department of Health thinks that a benchmark of one nurse to every 40 patients is not being overworked, and very often the nurses see even more people than that,’ says Serote.

Even for a thriving economic hub like Gauteng, prosperity is shared by only a few. Money can buy many things, it seems, but clearly it can’t buy solutions that are inclusive, innovative or impactful for a health-care system that needs just these.

Editorial: Three months to get it right

By Anso Thom and Marcus Low

Delays at the South African National AIDS Council (SANAC) has meant that the new NSP (National Strategic Plan) will now only be ready in March 2017. While the delay itself is not of any great concern, the kind of plan that will be produced by an unsettled SANAC and a weakened, unrepresentative civil society is concerning and brings into question the very idea of SANAC and the NSP. Already we are hearing rumours of a back-track on various things contained in draft zero of the NSP – including a back-track on the recommendation to decriminalize sex work.

There is a risk that over the next three months an NSP will take shape that will lack many of the targets and deadlines it needs to make an impact. It is understandable that government doesn’t want what they see as an external plan to interfere with their internal plans. But civil society should not accept this. We need leaders who can stand up to government, when needed work with them, but ultimately demand we do better on key issues such as sex work, condoms in schools, active case-finding for TB and community healthcare workers. Unfortunately, from what we’re hearing, civil society is capitulating on these issues without much of a fight.

Even though many critical issues will be mentioned in the eventual NSP, mere mentions are not enough. We need plans, timelines and budgets. We need an NSP that is highly focused and concrete. The decriminalization of sex work, for example, has been on the agenda for years – but simply having it on the agenda is not enough. We need to have a roadmap from where we are now to an actual amendment in our laws. Without such a roadmap, we do not in fact have a plan.

Similarly, setting targets for providing more people with HIV treatment and helping people adhere to treatment is all good and well, but targets are not a plan. How do we improve treatment adherence? Do we need to employ more community healthcare workers to provide adherence support and to trace patients who default? We think we should. How do we provide differentiated care through adherence clubs, if we don’t pay people to run those adherence clubs? How do we ensure there are no drug stockouts which endanger trust in the health system. How do we build a Medicines Control Council that can cope with the workload or registering new drugs and investigation unlawful treatment and activities? These are the issues the NSP must map out in detail and force action on. It should make the case so clearly and convincingly that the Department of Health and treasury has no option but to fund it.

In the same way, we can say whatever nice things we wish about active case-finding for TB (possibly the most critical TB intervention we are not implementing), but if we don’t map out what that means in the real world then it will be just an another aspirational target. The NSP has to make it explicit that we can’t do active case-finding without people and that we need to train and pay people to start doing active case-finding. In two words Community Health Workers.

Another critical area on which the new NSP must move the dial is HIV and pregnancy prevention in schools. We need a programme that is explicit about the right to comprehensive sex education and the right to access condoms – the latter being a right in terms of the right to access healthcare services. But again there appears to be no clear plan on the table on how we get from here to there.

If the new NSP doesn’t deliver on these critical issues with detailed timelines and budgets then it will be hard for us to support it. As has become clear in recent issues of Spotlight (previously NSP Review), our HIV and TB response is at code red. Our public healthcare system is in crisis. We need a plan that deals with this emergency seriously and based on the best available evidence. Anything less is not good enough.

A difficult political environment

The development of the new NSP comes at a very difficult time in South Africa’s history. Amid the Public Protector’s State Capture Report, the various scandals relating to the Gupta family, spurious charges against Finance Minister Pravin Gordhan and widespread calls for President Jacob Zuma to stand down, Deputy President and SANAC chair Cyril Ramaphosa has had a lot on his plate. In this fraught political context the new NSP has hardly elicited the national conversation or leadership that is needed – that it is needed is clear from the fact that around seven million people in South Africa now live with HIV and tens of thousands still die of tuberculosis every year.

To some extent, our HIV and TB response is also falling victim to the wider crisis in our politics. It is thus very encouraging that Health Minister Dr Aaron Motsoaledi and deputy Minister Joe Phaahla took a public stand against corruption when late in October they publically declared their support for Minister Gordhan. The spurious charges against Minister Gordhan have since been withdrawn. We trust that these leaders will not lose their jobs or be victimised for having taken this correct and principled stance. We will watch closely.

While the fight against corruption and state capture in South Africa is urgent and critical, the development of the new NSP is also critical. We urge the Deputy President, the Minister of Health, the rest of the national cabinet and all provincial cabinets to engage with both these urgent issues. Just like corruption, HIV and TB impacts the lives of millions of people in this country.

While the big picture politics are deeply concerning, there are also some signs that all is not what it should be at SANAC. The position of SANAC CEO Dr Fareed Abdullah was recently advertised amid rumours of a campaign to replace him with a person more compliant to the whims of some in government. Whether there is any veracity to these rumours we do not know, but it has reached us from various sources.

What is clear though is that in the current political context we need SANAC to be stronger than ever. Abdullah has done well in steering SANAC over the last five years and much of what concerns us at SANAC is beyond his control. Removing him now will threaten operational continuity at SANAC – something we cannot afford.

Civil society leadership crisis

While operational continuity is critical at SANAC, we urgently need new energy and ideas on the political side. This political energy has to come from civil society leaders at SANAC. Many people we have spoken to have expressed their disappointment with the failure of the current civil society representatives to raise critical issues impacting on ordinary people living with HIV and/or TB over the last five years. There is a strong feeling that SANAC needs a civil society sector that is fully representative, that speaks with the voices of the marginalized, speaks with the voices of the poor and that the only way in which this can happen is if the current civil society is disbanded.

The new NSP provides an opportunity to make a clean start where we avoid the pit-falls of the past and ensure that people living with HIV and TB in South Africa feel they are properly represented. One way to avoid these pit-falls is to set some guidelines of what we expect from our civil society representatives.

To start with, we should insist that civil society leaders must represent constituencies and not just themselves (academics and other technical experts can of course contribute in their personal capacities to technical questions). Ideally, we want people who have been elected by affected people and who must account back to those people on what they have or have not done at SANAC.

Secondly, we should insist on transparency regarding the financial affairs of all civil society representatives. Where people represent NGOs, the finances of those NGOs should be open for public scrutiny – as is the case with all NGOs. If people do business with government, then that potential conflict of interest should be disclosed.

Looking back, there is much to be proud of, but what lies ahead is what matters now and what we do in the next three months will set the course of the next five years.

 

How do we get to zero TB?

By Salmaan Keshavjee MD, PhD, ScM
Department of Global Health and Social Medicine
Harvard Medical School

 

Tuberculosis (TB) has surpassed HIV/AIDS as the biggest infectious killer of adults worldwide.  In 2015, an estimated 10.4 million people became sick with the disease—one million of whom were children—and 1.8 million people died.  That’s one person dying every 18 seconds from a disease that has been largely treatable since 1948.

Why do so many people die from this treatable disease?  Mostly because they are not diagnosed in time or do not receive the correct care.  In 2015, more than 40 percent of the estimated number of people with TB were not diagnosed and received no treatment.  An estimated 580 thousand people became sick with multidrug-resistant TB (MDR-TB), disease caused by Mycobacterium tuberculosis resistant to the two main drugs of the first-line anti-TB treatment regimen; only 22 percent of those individuals received treatment and less than half were cured.  Because the disease is airborne, those who are not diagnosed or do not receive the correct treatment continue to spread the disease in their families, communities and places of work.

Until recently, many countries faithfully adhered to the World Health Organization’s (WHO) DOTS strategy to tackle TB.  Introduced in 1993, the DOTS strategy proposed a limited set of interventions for low- and middle-income settings, aimed at “controlling” the epidemic. For the most part, the approach ignored some of the pillars of TB epidemic control that had nearly eliminated TB in rich countries: active case finding (including the screening of close contacts); rapid treatment of people sick with any form of the disease, including drug-resistant strains; and prophylaxis for individuals with TB infection that has not yet progressed to disease (e.g. isoniazid prophylaxis therapy, or IPT).

Why was this the case?  Sadly, the reasons had little to do with science.  For example, as early as 1964, the WHO’s Expert Committee on Tuberculosis discouraged the use of IPT outside of rich countries, “arguing that cost, logistical difficulties, the likelihood of defaulting, and other concerns all made it unfeasible.” (Macmillan 2015: 195).  This decision was reaffirmed in 1974 by another WHO expert committee, which, despite overwhelming data showing the benefits of IPT from the work of George Comstock and others in the United States, deemed the use of IPT “irrational”.  It was again reaffirmed in 1982 because of fears that treating TB infection would divert resources away from tackling active disease.  The WHO and its partner, the International Union Against Tuberculosis and Lung Disease (IUATLD), argued then that “in practice [IPT] has virtually no role in developing countries.” (Ibid).  Similar arguments—based primarily on dogma about cost and the belief that countries outside the “global north” would not be able to deliver more than a rudimentary level of care to their populations—were made about active case-finding and about the treatment of MDR-TB.  Instead, the DOTS strategy relied on passive case-finding—waiting for the sick to make it to a clinic—as well as diagnosis with sputum smear microscopy, a low-sensitivity test ill-suited for the diagnosis of children, people co-infected with HIV, people with extra-pulmonary TB, and those with disease caused by drug-resistant bacteria.  While the policies of the WHO have changed in some of these areas, systems built around delivering the DOTS strategy have not.

The result of ignoring these important facets of TB epidemic control—both a moral and scientific failure—has been the death of millions and a largely unabated epidemic.  Over the last decade, the decline in TB has been paltry: roughly 1.5% per year. If this trend continues, this means that it will take approximately 200 years for the global TB rate to reach the level seen today in North America and Europe.  It does not have to take this long.  In order to change this trajectory, countries like South Africa, India, China, Russia, Brazil, Indonesia, Kenya, Peru, Pakistan and many others, must take the bold step of instituting a comprehensive package of tried and tested approaches to stopping the TB epidemic.

So what should be done?  This comprehensive approach, which has been outlined by scholars and practitioners from 11 countries in a series in The Lancet called How to Eliminate Tuberculosis, is conceptually simple, but requires that we rethink the way we are struggling against TB.  The series outlines how we should clearly know the TB epidemic, using data and deploying epidemic control strategies as needed to different hotspots.  It also outlines a strategy of three interlinked components: SEARCH, TREAT, and PREVENT.

search

SEARCH means to actively find people sick with TB, as well as those infected with TB but who are at high risk of becoming sick.  Finding those people who are already sick with TB is critical because they are infectious and continue to spread the disease in their families and communities.  Finding out who has been infected or exposed to TB—and who may later become sick—is also a critical part of searching.  Data have clearly shown that people infected with TB have at least a five percent chance of becoming sick with active disease within the first two years after infection.  That’s one in twenty people that will get the disease and continue to transmit the disease in families and communities, even after the original index patient has been treated.  Thus, stopping the epidemic means finding these people and offering them post-exposure treatment. Where does one find individuals at most risk of developing TB?  Again, the data are quite clear: people living in the household of a TB patient have a one to five percent chance of having active TB; those seeking care in general health care facilities have a five to ten percent chance of having active TB; and individuals receiving HIV-associated care have a one to 25 percent chance of having active TB.  There are other high-risk groups—such as people working in mines, garment factories, or spending considerable time in other over-crowded areas—but households and health care facilities are certainly an important place to start looking.

TREAT means ensuring that people sick with TB get the quickest correct treatment for their TB, regardless of whether they have a drug-sensitive or drug-resistant strain.  The correct treatment of the disease stops people from dying, from having long-term sequelae from the disease, and stops transmission.  Studies from the 1950s, 1960s, and even recently, have shown that if a sick person is started on the correct therapy—a therapy capable of killing the strain of TB with which he or she is infected—he or she is no longer infectious.  Part and parcel of this is ensuring rapid and ready access to new anti-TB drugs and fast-tracking research on shorter and more efficacious regimens.  One can never forget that TB leads to an almost certain death—like many cancers—so the risk of initiating treatment with new drugs or drugs with adverse events is far outweighed by the benefits.

PREVENT means engaging in a set of activities that will help stop the transmission of TB.  First, it is critical to ensure that infection control measures are taken in health care facilities so that TB does not spread.  Second, it means ensuring that individuals infected with the TB bacillus, but who are not yet sick with TB disease, receive post-exposure treatment that will prevent their infection from progressing.  Pathbreaking studies from the 1960s showed that prophylaxis after infection—coupled, of course, with active case finding and treatment of people sick with TB—not only helped bring down the rates of TB dramatically, but reduced TB deaths for at least 20 years after the intervention.

As we know, TB is a disease that moves preferentially among the poor, the malnourished, and the immunocompromised.  People with HIV coinfected with TB have a 5 to 10 percent chance each year of becoming sick with TB; malnourished people with a low body mass index (BMI) have a ten-fold risk of getting TB.  This means that treatment and prevention will require ensuring that people sick with TB and those receiving post-exposure treatment have enough food to eat, that they have access to appropriate housing, and that their co-morbid conditions (e.g. HIV, diabetes, malnutrition) are cared for.  Because TB is itself a driver of poverty, prevention also requires health systems to engage in a multi-sectoral approach, including linking people and families sick with TB to innovative poverty-alleviation mechanisms.

The interventions that are part of the SEARCH, TREAT, and PREVENT (S-T-P) strategy will take a major push, and many will be tempted to implement them piecemeal.  This would be a mistake.  Both global experience and mathematical models suggest that deploying these interventions in combination will rapidly lower both TB cases and deaths.  Creating systems capable of implementing the S-T-P strategy will require resources, and in many cases, reorganization and integration of activities with other programs.  If done properly this will not only move us rapidly towards eliminating the scourge of TB, but the systems developed can be used to give care to people with asthma, diabetes, hepatitis C, and a number of other diseases.  Taking the correct steps to end the TB epidemic is vital to building our collective capacity to provide high quality universal health care.

References:

Cavalcante SC, Durovni B, Barnes GL, et al. Community-randomised trial of enhanced DOTS for tuberculosis control in Rio de Janeiro, Brazil. International Journal of Tuberculosis and Lung Disease 2010; 14: 203–09.

Cegielski JP, Arab L, Cornoni-Huntley J.  Nutritional risk factors for tuberculosis among adults in the United States, 1971-1992, American Journal of Epidemiology 2012; 176(5):409-22.

De Cock KM, Chaisson RE. Will DOTS do it? A reappraisal of tuberculosis control in countries with high rates of HIV infection. International Journal of Tuberculosis and Lung Disease 1999; 3: 457–65.

Dye C, Glaziou P, Floyd K, Raviglione M. Prospects for tuberculosis elimination.  Annual Review of Public Health 2013; 34: 271–86.

McMillen, CW.  Discovering Tuberculosis: A global history 1900 to the present.  New Haven: Yale University Press, 2015.

Obermeyer Z, Abbott-Klafter J, Murray CJL. Has the DOTS strategy improved case finding or treatment success? An empirical assessment. PLoS One 2008; 3: e1721.

Ortblad KF, Salomon JA, Bärnighausen T, Atun R. Tuberculosis control for sustainable development. Lancet 2015; 386(10010): 2354-2362.

Rangaka MX, Cavalcante SC, Marais BJ, et al.  Controlling the seedbeds of tuberculosis: diagnosis and treatment of tuberculosis infection. Lancet 2015; 386(10010): 2344-53.

Theron G, Jenkins HE, Cobelens F, et al. Data for action: collecting and using local data to more effectively fight tuberculosis. Lancet 2015; 386(10010): 2324-33.

Yuen C, Amanullah F, Dharmadhikari A, et al. Turning off the tap: Stopping tuberculosis transmission through active case-finding and prompt effective treatment. Lancet 2015; 386(10010):2334-43.

 

 

TB: What the numbers tell us about political will

By Marcus Low

Last month the annual Union World Conference on Lung Health was held in Liverpool, United Kingdom. As always at this conferences, much was said about how the world needs to step up the fight against tuberculosis (TB) – about how we need new agendas and paradigm shifts.

Unfortunately, new data released at the conference and in the preceding weeks paint a very bleak picture of the global TB response. The severity of the crisis is unquestionable. Per the World Health Organisation’s Global Tuberculosis Report 2016, 1.8 million people died of TB in 2015, there were 10.4 million new TB infections in the same year and over half a million (580 000) of those cases were drug resistant forms of TB.

How is the world responding to this crisis? Well, according to Treatment Action Groups (TAG) annual report into TB R&D, not good. Their report reveals that the already low investment in TB research has declined even further in 2015. The entire global investment in that year was $621 million. This is less than a third of the $2 billion that the WHO estimates is needed per year. That the entire world together can’t even come up with this comparatively small amount (given the size of national budgets) is mind-boggling.

As Mike Frick of TAG recently pointed out in Spotlight, the situation is even bleaker when looking at high burden countries. The BRICS (Brazil, Russia, India, China, South Africa) have roughly half of the world’s TB cases and TB deaths, but only contribute 4.3% of public funding for TB research. South African universities received more TB research funding from the US National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation than from the South African Medical Research Council or other domestic agencies. With a Trump presidency in the United States, it is unclear whether even these NIH funds will be there in future. (For those who are interested, there is a petition calling for BRICS to triple investment in TB R&D.)

The inescapable conclusion is that, even though TB is killing their citizens, BRICS nations do not see TB research as a priority. This is fundamentally a political problem. Most people who die of TB are poor and not politically well-enough organised to advocate for a better TB response. And, unfortunately, with a lack of grassroots political pressure most politicians remain indifferent to TB – the one notable exception being South Africa’s Minister of Health Dr Aaron Motsoaledi.

India has more TB cases and TB deaths than any other country. It is the epicentre of the TB epidemic much like South Africa is the epicentre of the HIV epidemic. Yet, while the Indian government has made several encouraging announcements regarding its TB response, almost two years after making these announcements they have failed to implement many of the things they have promised. These include absolute no-brainers like daily fixed-dose combination TB treatment for people with HIV and the provision of appropriately dosed pediatric FDC treatment for children. When activists interrupted Jagdish Prasad, Director General of Health Services of the Government of India, he responded by telling media that the activists are “unstable” and “mentally unwell”.

But one wonders why it was left mostly to activists to call out India’s broken TB promises. For all the talk of paradigm shifts and new agendas, most of the TB establishment seems more committed to politeness and quiet diplomacy than to doing what it takes to bring about a paradigm shift.

This inertia may in part be explained by the fact that many in the TB establishment are from and live in countries where there is very little TB. Incidentally, as pointed out in a recent civil society letter, of the 10 Union World Conferences on Lung Health from 2007 to 2016, six were held in Europe (none of which were in Eastern Europe), two in Africa (both in Cape Town), one in North America and one in Asia. Mostly, the conferences are where the TB is not.

There is nevertheless some limited reasons for hope. Firstly, there are a number of good researchers and healthcare professionals dedicating themselves to TB research under often very difficult conditions. As with the very encouraging early results from a trial of a new XDR TB treatment, these efforts are already resulting in life-saving advances. We must urgently do more to support these researchers and to encourage more medical researchers to work in TB a big part of that will be finding more money for TB research.

Secondly, and getting back to TB’s bigger picture political problem, there appears to be a growing awareness among at least a small group of committed people that we need to politicise TB outside of these annual conferences. Two things stand out in this regard: the push for a UN High Level Meeting (HLM) on TB and the growth of the Global TB Caucus of parliamentarians. In both the HLM and in the work of the TB Caucus, it will be difficult to find the correct balance between staying politically correct and saying what needs to be said – for example in relation to India. As was the case with HIV, we will need bureaucrats, diplomats and researchers to step out of their comfort zones and to become activists.

As always, most governments and government officials will attempt to underplay the TB crisis in their countries and the short-comings in their own responses. We should not stand for such short-sightedness. The numbers make it clear that TB is an urgent crisis in the lives of millions. We should allow it to become a political crisis as well. Only then will we see the paradigm shift people keep talking about.