Bridging the Accountability Gap in Our Fight against TB

Twenty-thousand years ago, at the peak of the last ice age, early human ancestors were migrating from their origins in Africa to East Asia. Shards of the earliest known pottery found in a cave in China suggest that our progenitors were dabbling in cooking. The Upper Paleolithic era led to more than domestication, however. It also likely gave rise to the bacteria that are common ancestors to modern day tuberculosis.

The disease has been plaguing humans ever since. Egyptian mummies show signs of TB. It’s mentioned in the Bible and in the writings of the ancient Greeks. The medical community isolated the bacteria in 1882, and has been actively fighting it with public health efforts. 

The bacteria have prevailed. Today, it’s the world’s number one infectious disease killer, particularly in the most resource-strapped countries. It is also the leading killer of people living with HIV and AIDS.

Clearly, we need a major change in our approach to ridding the world of TB. Diagnosing, curing, and preventing the disease — while avoiding catastrophic costs — requires a hard look at how programs perform and effectively integrate into health systems.

A bill currently moving through the U.S. Congress supports these efforts. It is the first proposed piece of legislation in five years dealing with our response to TB, and it differs from former bills in that it mandates detailed monitoring and regular reporting of key performance indicators.

It calls for independent bodies to ensure government, organizational, and program accountability. It also calls for countries to routinely measure progress and make sure everyone involved keeps their commitments, from making sure required TB policies and infrastructure are in place to earmarking resources and spending. 

That will force recipients of donor investments to not only use their resources efficiently but also make every effort to discern which interventions actually work. It also mandates program partners — whether they be nations, NGOs, or private sector and faith-based organizations — to collaborate on accurate reporting.

Tuberculosis can be tricky to diagnose. Treatment is complicated and can last for months. Patients who don’t complete it may continue to infect others, and treatment interruption can contribute to antimicrobial resistance. That’s more likely to happen when patients visit private clinics, which in many countries are less likely to adhere to national treatment standards.

Collaboration also helps ensure a more comprehensive, systemic approach — one in which governments, hospitals, health workers, private-sector providers, and donors provide a seamless response to a problem as complex as TB. That’s important, as you cannot simply look to eradicate a disease in a country without also addressing the health system in which that country operates. 

Yet there is still much work to do in many countries before they can fully commit to and be accountable for planning, funding, and executing efficient and effective programs to eliminate TB. Donors and nonprofits must help support necessary governing structures, regulatory and financial environments, and skills.

For example, Ethiopia’s TB program suffered from a scattered, weak network for referring, collecting, and transporting disease-testing specimens and results, which hindered patient care and follow-up. Samples were often destroyed due to a lack of refrigeration. 

Management Sciences for Health helped the country set up an integrated specimen transport system, including eight refrigerator-fitted vans, to serve 163 health facilities.

In almost three years, the system handled 85,250 specimens, reduced testing time from as long as a week to just one day, and dramatically reduced the specimen rejection rate. Importantly, the benefits extended to other health programs as well, with the fleet also handling a significant number of HIV and DNA tests.

Importantly, the bill calls for U.S. help in establishing a method to independently verify that countries are taking responsibility for fighting TB inside their own borders. Financial commitments by national governments have lagged far behind the health need: The funding gap for TB now reaches $22.5 billion. 

Moreover, that gap is widest in Africa, Eastern Europe and Southeast Asia, where the TB burden is highest. The bill also calls for annual reporting on how the U.S.AID TB program is performing, including countries’ roles in it, and how effectively funds are used.

Fully funding our work to end TB is critical, as is continuing to support countries in doing their part to build their own effective, self-reliant health systems. But we cannot afford to continue business as usual. I welcome this new era of transparent, accountable action. It’s this modern perspective that will vanquish, finally, one of the world’s most ancient killers.

---

Ersin Topcuoglu, M.D., MPH is senior principal technical advisor at Management Sciences for Health, a global nonprofit that works with leaders in low- and middle-income countries to build strong, equitable, and sustainable health systems that save lives and improve health outcomes.