Planning to improve global health: the next decade of tuberculosis control

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1 Plnning to improve globl helth: the next decde of tuberculosis control Dermot Mher, Chris Dye, Ktherine Floyd, Andre Pntoj, Knut Lonnroth, Alsdir Reid, Ev Nthnson, Thd Penns, Uli Fruth, b Jne Cunninghm, c Hether Igntius, d Mrio C Rviglione, Irene Koek e & Mrcos Espinl f Abstrct The Globl Pln to Stop TB is rod mp for policy-mkers nd mngers of ntionl progrmmes. It sets out the key ctions needed to chieve the trgets of the Millennium Development Gols relting to tuberculosis (TB): to hlve the prevlence nd deths by 2015 reltive to 1990 levels nd to sve 14 million lives. Developed by brod colition of prtners, the pln presents model pproch combining interventions tht cn fesibly be supplied on the ground. The min res of ctivity set out in the pln re: scling up interventions to control tuberculosis; promoting the reserch nd development of improved dignostics, drugs nd vccines; nd engging in relted ctivities for dvoccy, communictions nd socil mobiliztion. Scenrios for the plnning process were developed; these looked t issues both globlly nd in seven epidemiologicl regions. The scenrios mde mbitious but relistic ssumptions bout the pce of scle-up nd implementtion coverge of the ctivities. A mthemticl model ws used to estimte the impct of scling up current interventions bsed on dt from studies of tuberculosis biology nd from experience with tuberculosis control in diverse settings. The estimted costs of the ctivities set out in the Globl Pln were bsed on implementing interventions nd reserching nd developing drugs, dignostics nd vccines; these costs were US$ 56 billion over 10 yers. When trnslted into cost per disbility djusted life yer verted, these costs compre fvourbly with those of other public helth interventions. This pproch to plnning for globl tuberculosis control is vluble exmple of developing plns to improve globl helth tht hs relevnce for other helth issues. Bulletin of the World Helth Orgniztion 2007;85: الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. espñol. Une trduction en frnçis de ce résumé figure à l fin de l rticle. Al finl del rtículo se fcilit un trducción l Introduction When the elephnts fight, the grss gets trmpled this phorism exemplifies the vigorous debte over the best pproch to plnning for development. The debte positions Jeffrey Schs, 1 proponent of comprehensive supply-side blueprint, ginst Willim Esterly, 2 proponent of more specific solutions tht respond to locl demnds. In the trmpled grss lies n pproch to plnning tht combines the benefits nd minimizes the drwbcks of both these pproches. Amrty Sen recommends using n optiml plnning process whereby interventions tht cn potentilly be supplied re mtched ginst ground-level explortions of wht is fesible. 3 This is exemplified by the globl plnning for tuberculosis (TB) control over the next decde tht hs been undertken by the diverse colition of stkeholders in the Stop TB Prtnership. The Stop TB Prtnership is globl movement to ccelerte socil nd politicl ction ginst tuberculosis. The network of prtners includes interntionl orgniztions, countries, donors (from both the public nd privte sectors), individuls nd governmentl nd nongovernmentl orgniztions. The prtnership ws estblished in 2000 to relize the gol of eliminting tuberculosis s public helth problem by The prtnership s secretrit is housed within WHO. The prtnership hs seven working groups, ech providing focus for coordinted ction in prticulr re of ctivity (Box 1). As rod mp both for policymkers nd mngers of ntionl progrmmes, the Globl Pln to Stop TB sets out the key ctions needed to implement interventions to control tuberculosis, such s cse-finding, tretment nd preventive tretment for high-risk groups, 5 s well s ctions needed for reserch nd development of improved tools such s dignostics, drugs nd vccines. The pln is oriented towrds chieving the interntionl trgets linked to the Millennium Development Gols: to hlve prevlence nd deths by 2015 reltive to 1990 levels. 6 These trgets represent step towrds the Stop TB Prtnership s vision of tuberculosis-free world by In this pper we outline the generl rtionle for plnning for control of communicble diseses, describe briefly Stop TB Deprtment, WHO, Genev, Switzerlnd. b Deprtment of Immuniztion, Vccines nd Biologicls, WHO, Genev, Switzerlnd. c Specil Progrmme for Reserch nd Trining in Tropicl Diseses, WHO, Genev, Switzerlnd. d Working Group on New Drugs, Stop TB Prtnership, New York, NY, USA. e Infectious Diseses Division, Bureu for Globl Helth, US Agency for Interntionl Development, 1300 Pennsylvni Ave., Wshington, DC 20523, USA. Correspondence to Irene Koek (e-mil: ikoek@usid.gov). f Stop TB Prtnership Secretrit, WHO, Genev, Switzerlnd. doi: /BLT (Submitted: 19 October 2006 Finl revised version received: 29 Jnury 2007 Accepted: 12 Februry 2007) 341

2 Specil theme Tuberculosis control the process nd outcomes of globl plnning for tuberculosis control, nd then review the policy implictions of longterm plnning for tuberculosis control to illustrte the vlue of the plnning process. Bckground Communicble diseses constitute lrge proportion of the globl burden of morbidity nd mortlity, ccounting in 2002 for 24% of the globl burden of disbility-djusted life yers (DALYs) nd 19% of globl deths. 8 Globliztion not only poses threts regrding communicble disese control; it lso provides opportunities. 9 Awreness of the globl burden nd thret of communicble diseses s well s opportunities for control hve led to the development of mny interntionl prtnerships nd llinces to coordinte efforts to control such diseses. Good exmples include the globl cmpign in the 1960s nd 1970s tht erdicted smllpox, 10 the progrmme since 1974 to control onchocercisis in west 11 nd, more recently, the development of the GAVI Allince (formerly the Globl Allince for Vccines nd Immuniztion) 12 nd the Stop TB Prtnership. 13 The effectiveness nd efficiency of interntionl collbortions depends on sound plnning. Exmples of plns for globl control of n cute communicble disese include those relted to poliomyelitis; 14 n exmple relted to chronic communicble disese includes those plns relted to leprosy. 15,16 Long-term plnning is necessry to control epidemics of chronic communicble diseses, such s leprosy nd tuberculosis, tht chnge reltively slowly owing to the specific dynmics of disese trnsmission. Tuberculosis excts n nnul globl toll of 8.8 million new cses nd 1.6 million deths. 17 The min res of ctivity set out in the pln re: scling up the use of interventions for tuberculosis control; promoting reserch nd development of improved dignostics, drugs nd vccines; nd promoting relted ctivities for dvoccy, communictions nd socil mobiliztion, including the crucil prts plyed by ptients nd communities in implementing the pln. These ctivities dovetil with WHO s new Stop TB Strtegy 18 nd re oriented towrds chieving the interntionl trgets for The Stop TB Strtegy builds on the DOTS strtegy (the policy pckge comprising politicl commitment, bc- Box 1. The Stop TB Prtnership s working groups Working group DOTS expnsion Multidrug-resistnt TB TB/HIV Advoccy, communiction nd socil mobiliztion New TB dignostics New TB vccines New TB drugs teriologicl cse detection, stndrdized supervised tretment, effective drug supply nd n evlution system). 19 As recognized in the Stop TB Strtegy, scling up implementtion of interventions for tuberculosis control involves both collbortion cross the helth sector nd the need to focus on specil popultions. Purpose Dermot Mher et l. To expnd the coverge of DOTS, WHO s recommended strtegy for tuberculosis control To integrte surveillnce for drug resistnce nd the mngement of multidrug-resistnt TB into routine components of TB control by providing ccess to dignosis nd tretment for ll ptients nd engging ll helth-cre providers To reduce the globl burden of HIV-relted TB by implementing effective collbortion between TB nd HIV progrmmes nd communities, nd by promoting evidence-bsed collbortive ctivities to control TB nd HIV To chieve TB-free communities by using globl nd country-level dvoccy, s well s communiction nd socil mobiliztion techniques To implement reserch, dvoccy nd/or opertionl ctivities to develop tools to dignose TB nd to meet the ims of the prtnership To bring together the wide rnge of interntionl groups with n interest in developing TB vccine; to ccelerte the identifiction nd introduction of the most effective vccintion strtegy To ensure tht scientists, cdemics, phrmceuticl compnies, donors, multilterl gencies nd ptients re working together to speed the development of new drugs for TB Methods Ech of the prtnership s seven working groups developed strtegic pln of ctivities to contribute to the overll pln. Three of the working groups re concerned with implementing interventions: the DOTS expnsion group, the multidrug-resistnt tuberculosis (MDR- TB) group nd the tuberculosis/hiv group (Box 1). They developed regionl nd globl scenrios to ssess the impct nd costs of the plnned scle-up of ctivities from 2006 to Scenrios were developed with the input of colition of prtners to ssess the globl impct nd costs s well s the impct in seven epidemiologicl regions (excluding the estblished mrket economies nd centrl Europe, which ccount for only 1.7% of the globl totl of TB cses.). The scenrios involved mbitious but relistic ssumptions bout the pce of scle-up nd the implementtion coverge of ctivities. In the bredth of the colition s representtion (which included groups of ctivists nd representtives of civil society groups, governments, cdemics, United Ntions orgniztions, nongovernmentl orgniztions nd technicl experts), this colition mde unique contribution to Sen s fvoured pproch to globl plnning. The groups concerned with reserch nd development (dignostics, drugs nd vccines) nd the dvoccy, communictions nd socil mobiliztion group developed strtegic plns bsed on ech group s consensus view, but they did not estimte these ctivities expected epidemiologicl impcts. A mthemticl model ws used bsed on previous modelling 20,21 to estimte the potentil impct of scling up interventions; levels of tuberculosis cse detection nd tretment outcomes were estimted for the next 10 yers. Dt from studies of tuberculosis biology nd from tuberculosis control experience in diverse settings were brought together to model the impct on tuberculosis prevlence, incidence nd deth rtes in reltion to the 2015 trgets. The two min components in estimting costs funding nd funding gps were nlysed in reltion to the implementtion of interventions nd the reserch nd 342

3 Dermot Mher et l. Specil theme Tuberculosis control development of new dignostics, drugs nd vccines. 22 Findings The modelling outcomes were represented in terms of the number of people benefiting from interventions nd the progress towrds trgets (i.e. the impct on disese burden). From 2006 to 2015, totl of bout 50 million people will be treted for tuberculosis under the Stop TB Strtegy. This totl includes ptients with MDR-TB nd 3 million ptients infected with both tuberculosis nd HIV who will be enrolled in ntiretrovirl therpy. Implementing the pln would result in 14 million lives sved compred with sitution in which the DOTS strtegy is not implemented. In terms of the impct of the plnned scleup, estimtes indicte tht the strtegy would be expected to chieve the globl trget for 2015 for prevlence nd deths (mesured ginst the 1990 bseline) with considerble progress mde in ll regions (mesured over the plnning period ). (Fig.1 nd Fig. 2.) Becuse of the surge in tuberculosis in since 1990 (s consequence of the HIV epidemic) nd in estern Europe (s consequence of socioeconomic turmoil in ddition to the emergence of MDR-TB), these regions re likely to chieve these trgets fter Additionl scenrios identified the mesures needed to chieve the trgets in these two regions. There would need to be mssive improvements in the generl helth systems, 50% reduction in Fig. 1. Expected prevlence of ll forms of tuberculosis in 2015 under implementtion of the Globl Pln to Stop TB in comprison with trgets (countries included in ech region cn be found in the text of the pln) Prevlence/ popultion high-hiv low-hiv Europe Region Ltin Americ Mediterrnen South- Est Asi Trget Expected under pln Western Pcific All regions The trget is light green. The number expected under pln is drk green when the trget is likely to be met, nd grey when it is not likely to be met. Fig. 2. Expected number of deths from ll forms of tuberculosis in 2015 under implementtion of the Globl Pln to Stop TB in comprison with trgets (countries included in ech region cn be found in the text of the pln) No. of deths/ popultion per yer high-hiv low-hiv Europe Region Ltin Americ Mediterrnen South- Est Asi Trget Expected under pln Western Pcific All regions The trget is light green. The number expected under pln is drk green when the trget is likely to be met, nd grey when it is not likely to be met. HIV incidence nd rpid vilbility of new tools to increse dignostic cpcity, substntilly shorten tretment durtion, nd effectively prevent tuberculosis. Even substntil mounts of dditionl funding nd greter effort re unlikely to succeed in overcoming these constrints by The Globl Pln to Stop TB builds on the trck record of the first Globl Pln ( ), in which US$ 5 billion ws budgeted, rised nd spent, with doubling of ptients treted under the DOTS strtegy from 2 million in 2000 to more thn 4 million in The totl US$ 56 billion cost of the current pln represents threefold increse in nnul investment in tuberculosis control compred with the first Globl Pln. As shown in Tble 1, this totl includes US$ 47 billion for scling up interventions nd US$ 9 billion for reserch nd development. The totl estimted funding gp is US$ 31 billion, since n estimted US$ 25 billion is likely to be vilble bsed on projections of trends in funding (both domestic nd externl). These projections include the contributions mde by vrious funding sources to the budgets of ntionl tuberculosis control progrmmes, including the World Bnk, bilterl donors nd the Globl Fund to Fight AIDS, Tuberculosis nd Mlri. Out of totl need of US$ 47 billion to scle up interventions (Tble 1), the funding likely to be vilble is estimted t US$ 22.5 billion, leving US$ 25 billion funding gp, which requires incresed funding commitments from ntions nd donors. The shortfll in funding vilble for scling up increses from US$ 1.4 billion in 2006 to US$ 3.1 billion in At totl scle-up cost of US$ 47 billion, the globl cost-effectiveness is US$ 157 per DALY verted. (Detils of this nlysis re vilble from the corresponding uthor upon request.) The verge globl cost per ptient treted under the pln is US$ 448, rnging from US$ 151 in WHO s South-Est Asi Region to US$ 1732 in estern Europe. Clculting the cost of scle-up on per-cpit popultion bsis, the cost per person per yer is lowest in Ltin Americ, South-Est 343

4 Specil theme Tuberculosis control Dermot Mher et l. Tble 1. Totl costs, vilble funding nd funding gps in the Globl Pln to Stop TB , s compred with the first Globl Pln, Globl Pln to Stop TB (10-yer pln) First Globl Pln (5-yer pln) Costs Avilble funding Funding gp Costs Totl implementtion Country costs b 22.5 DOTS expnsion Strtegy for multidrug-resistnt tuberculosis TB/HIV collbortive ctivities Advoccy, communiction nd socil mobiliztion progrmmes Interntionl gencies (technicl coopertion) c Totl new tools Vccines d Drugs Dignostics Totl costs All mounts shown in billions of US$. Column totls my not dd up exctly due to rounding. b The figures for domestic funding ssume tht governments commitments in 2005 re sustined nd increse in line with infltion; commitments from the Globl Fund to Fight AIDS, Tuberculosis nd Mlri re bsed on results. c Technicl coopertion includes strtegic nd technicl support, cpcity building, monitoring nd evlution, opertionl reserch, policy development nd working groups. d This ctegory includes costs for mintennce of the current BCG (bcille Clmette Guérin) vccintion progrmme. Asi, the Western Pcific nd the Mediterrnen; these re res where it rnges from US$ 0.10 to US$ In n countries with low prevlence of HIV nd in estern Europe, costs rnge from US$ 0.90 to US$ In countries in with high prevlence of HIV, costs rnge from US$ 1.30 to US$ Discussion From 2006 to 2015, totl of 50 million people will be treted for tuberculosis under the Stop TB Strtegy. Treting n verge of 5 million people per yer over the next 10 yers is fesible nd relistic: 26 million people with tuberculosis (both new cses nd relpsed cses) were treted under the DOTS strtegy from 1995 to 2005, of whom 4.9 million were treted in The key finncil outcomes of the process of developing the pln included estimting the globl cost of ctivities (US$ 56 billion) tht will be oriented towrds chieving the prtnership s trgets for 2015 nd estimting the likely funding gp (US$ 31 billion). There re two mjor resons why the funding gp increses from US$ 1.4 billion in 2006 to US$ 3.1 billion in The first is tht the estimtes of funding re bsed on the ssumptions tht domestic funding will be sustined t 2005 levels nd tht donor funding (excluding funding from the Globl Fund to Fight AIDS, Tuberculosis nd Mlri) will be sustined t 2004 levels. The second is tht the pln includes lrge investments in new pproches, which is in keeping with the Stop TB Strtegy. These investments will include new pproches to implementing DOTS s well s more widespred implementtion of the mngement of MDR-TB, collbortive ctivities to control tuberculosis nd HIV, nd dvoccy, communiction nd socil mobiliztion ctivities. The pln lso includes much more investment in technicl coopertion (t round n verge of US$ 290 million per yer), which is needed to support this substntil increse in both the number nd scle of interventions. These dditionl lrge investments will require incresed funding commitments both from governments of countries with high burden of tuberculosis nd from foreign donors. Given the existing distribution of funding for tuberculosis control nd the size of the funding gp, it is likely tht governments in countries where there is high burden will need to finnce lrge proportion of this gp themselves. Filling the funding gp would require donor funding to increse bout eight times, wheres domestic funding would need only to double. The globl cost-effectiveness of US$ 157 per DALY verted compres fvourbly with tht of other helth interventions, s described in the Disese Control Priorities Project. 23 For nerly ll regions, the cost per DALY verted is less thn US$ 1 dollr per dy. The exception is in estern Europe, where the cost per DALY verted is close to US$ 2100 owing to extensive relince on reltively expensive hospitliztion of ptients during tretment for drug-susceptible tuberculosis nd becuse of the much higher costs of mnging MDR-TB. Tuberculosis control in South-Est Asi nd the Western Pcific is prticulrly cost-effective t bout US$ per DALY verted. The DOTS strtegy is mong the most cost-effective of ll helth interventions. The tuberculosis control interventions in the pln represent n enhnced DOTS strtegy tht is being used s prt of the new Stop TB Strtegy; despite being more comprehensive, this strtegy is still cost-effective. In order to relize the pln s expected gins, globl strtegic directions will need to be trnslted into ntionllevel ction nd funding through the use of more detiled plnning. This plnning must be tilored to regions nd countries specific needs. Long-term regionl nd ntionl plns, bsed on estimtes of impct nd costs of proposed ctions, 344

5 Dermot Mher et l. will provide powerful tools for policymkers nd progrmmes. The lck of long-term ntionl plnning ws identified s brrier to progress in tuberculosis control, spurring the doption of the 2005 World Helth Assembly resolution on sustinble finncing for tuberculosis prevention nd control. 24 The plnning outcomes hve implictions for the future prospects of longterm tuberculosis control. Projections show tht continued implementtion of the plnned interventions t the level of scle-up reched in 2015 will not result in the prtnership s vision of eliminting tuberculosis by 2050 (Fig. 3). The verge rte of decline in tuberculosis incidence tht is expected to be reched globlly between 2010 nd 2015 is 5 6% per yer. Under this pln, the incidence in 2050 will still be bout 100 times greter thn the elimintion trget of 1 cse per million popultion. In ddition to scling up interventions, new tools will be needed to meet this long-term gol by more effectively reducing trnsmission nd thereby preventing infection. They re lso needed to prevent tuberculosis mong people lredy infected, by decresing rectivtion of ltent infection. This my be chieved through mss tretment of ltent infection (idelly by specificlly trgeting those infected people most likely to develop tuberculosis) or mss vccintion. 25 The development pthwy for ech new tool hs high ttrition rte. The chnces of successful product emerging from the end of the development pipeline depend in prt on the number of potentil products entering the pipeline. 26 To keep the pipeline stocked, incresed investment is necessry not only in product reserch nd development, but lso in bsic reserch on pthogenesis nd immunology. Although the plnning process ws successful, the proof of the pudding is in the eting nd the pln s success depends on how it is implemented, specificlly on the extent to which the pln helps mobilize the needed funds for plnned ctivities nd how successful countries re in implementing ctivities. Criticl evlution of progress in implementing the pln will revel the degree of success or filure encountered in trnslting into ction the politicl commitment Incidence/ popultion per yer mobilized in developing nd lunching the pln. While the ssumptions tht underpinned the pln s development were bsed on the best understnding of the plnning nd epidemiologicl prmeters t the time, mesurements of progress in implementing ctivities nd their impct will enble testing nd refining of these ssumptions. The estimtes of tuberculosis prevlence (Fig. 1 nd Fig. 2) in the two epidemiologicl regions of sub-shrn (i.e. those countries with high HIV prevlence nd those with low HIV prevlence) provide n exmple of this. The estimted tuberculosis prevlences reflect estimtes of the risk of deth mong tuberculosis ptients: the high risk of deth mong HIV-positive ptients with tuberculosis results in lower tuberculosis prevlence in the region of countries with high HIV prevlence, compred with the region of countries where there is low HIV prevlence. As prt of mesuring the pln s impct, improved ssessments of life expectncy mong HIV-positive nd HIV-negtive ptients with tuberculosis will enble testing nd refining of the ssumptions underpinning prevlence estimtes. The need for flexibility in dopting nd dpting the pln is highlighted by the problem of extensively drug-resistnt tuberculosis, which hs emerged s key issue since the pln s publiction. 27 Specil theme Tuberculosis control Fig. 3. Projected tuberculosis incidence plotted on liner scle nd logrithmic scle Yer Arithmetic scle Logrithmic scle Incidence/ popultion per yer Conclusion This pproch to plnning globl tuberculosis-control ctivities is vluble s n exmple of using plnning to improve globl helth. Bsed on wide consensus, interventions tht cn potentilly be supplied were mtched ginst groundlevel explortions of wht is fesible; this ws done in keeping with the pproch dvocted by Sen. A consensus pln bsed on sound epidemiologicl nlysis with robust budget justifictions presents convincing rgument for mobilizing the resources needed for ction. It lso provides mens of ensuring ccountbility, since progress is mesured ginst ctul milestones. O Acknowledgements The uthors grtefully cknowledge the contributions of the Globl Pln Study Tem nd of ll contributors listed in the pln (see globlpln). Funding: The Globl Pln to Stop TB s development ws funded by the Stop TB Prtnership through contributions from the Netherlnds Ministry of Foreign Affirs, the Open Society Institute, the United Kingdom Deprtment for Interntionl Development, the United Sttes Agency for Interntionl Development nd the World Bnk. Competing interests: None declred. 345

6 Specil theme Tuberculosis control Dermot Mher et l. Résumé Améliortion de l snté dns le monde : plnifiction des ctivités de lutte ntituberculeuse pour l prochine décennie Le pln mondil Hlte à l tuberculose fournit sur des hypothèses mbitieuses, mis rélistes, qunt u rythme des lignes directrices ux décideurs politiques et ux directeurs de pssge à l échelle supérieure et de développement de l de progrmmes ntionux. Il présente les interventions clés couverture des ctivités. Un modèle mthémtique été utilisé nécessires à l rélistion des objectifs du Millénire pour le pour évluer l impct du pssge à l échelle supérieure des développement concernnt l tuberculose (TB), à svoir fire interventions en cours à prtir de données d études biologiques bisser de moitié, entre 1990 et 2015, l prévlence de cette sur l tuberculose et de l expérience cquise dns divers contextes mldie et l mortlité lui étnt imputble et éprgner 14 millions en mtière de lutte ntituberculeuse. de vies. Mis u point pr un vste groupement de prtenires, le Les estimtions de coûts pour les ctivités prévues pln propose un modèle de strtégie ssocint des interventions pr le Pln mondil correspondent à l mise en œuvre des fciles à mettre en œuvre sur le terrin. Les principux domines interventions et ux trvux de recherche et développement de d ctivité prévus sont : le pssge à l échelle supérieure des médicments, d outils dignostiques et de vccins méliorés ; interventions de lutte ntituberculeuse, l promotion des elles se montent à US$ 56 millird sur 10 ns. Une fois convertis trvux de recherche et développement concernnt des outils en coûts pr nnée de vie corrigée de l incpcité (DALY), ces dignostiques, des médicments et des vccins plus performnts chiffres supportent fvorblement l comprison vec ceux et l enggement dns des ctivités connexes de plidoyer, de d utres interventions de snté publique. Cette strtégie de communiction et de mobilistion socile. plnifiction de l lutte contre l tuberculose u niveu mondil Des scénrios ont été développés pour ider u processus est un exemple utile de progrmme de développement pour de plnifiction : ils considèrent les problèmes à l échelle mondile l méliortion de l snté dns le monde, qui intéresse d utres et dns sept régions épidémiologiques. Ces scénrios reposent problèmes snitires. Resumen Plnificr ls mejors de l slud mundil: l luch ntituberculos en l próxim décd El Pln Mundil pr Detener l Tuberculosis es un en siete regiones epidemiológics. Los escenrios prtín de hoj de rut pr instncis normtivs y gestores de progrms hipótesis mbicioss pero relists sobre el ritmo de expnsión y ncionles. En él se estblecen ls principles intervenciones l cobertur de plicción de ls ctividdes. Se utilizó un modelo necesris pr lcnzr ls mets de los Objetivos de Desrrollo mtemático pr estimr l repercusión de l expnsión de ls del Milenio relcionds con l tuberculosis: reducir l mitd intervenciones ctules sobre l bse de dtos procedentes de l prevlenci de est enfermedd y l mortlidd por es cus estudios de l biologí de l tuberculosis y de l experienci de l pr 2015 en comprción con los niveles de 1990 y slvr sí luch ntituberculos en diversos entornos. 14 millones de vids. Elbordo por un mpli colición de Los costos estimdos de ls ctividdes estblecids socidos, el pln present un modelo que combin diverss en el Pln Mundil -correspondientes l ejecución de ls intervenciones que pueden plicrse de form vible sobre el intervenciones y l investigción y el desrrollo de medicmentos, terreno. Ls áres principles de ctividd contemplds en el medios de dignóstico y vcuns- scendín US$ pln son ls siguientes: expnsión de ls intervenciones de luch millones lo lrgo de 10 ños. Trducidos l costo por AVAD (ños ntituberculos; promoción de l investigción y el desrrollo de vid justdos en función de l discpcidd) evitdo, l cifr de mejores medios dignósticos, medicmentos y vcuns; y es más bj que l de otrs intervenciones de slud públic. Este prticipción en ls ctividdes relcionds con l promoción, método de plnificción del control mundil de l tuberculosis ls comunicciones y l movilizción socil. brind un vlioso ejemplo pr elborr plnes de mejor de Se desrrollron distintos escenrios pr el proceso de l slud mundil que revistn interés pr otros problems plnificción, considerndo los problems nivel mundil y snitrios. ملخص التخطيط لتحسني الصحة يف العامل: العقد القادم ملكافحة السل ت عد الخطة العاملية لدحر السل مبثابة خارطة طريق ألصحاب القرار السيايس ومديري الربامج الوطنية فهي توط د األنشطة الرئيسية الالزمة لتحقيق املرامي اإلمنائية لأللفية وأهدافها املتعل قة بالسل وهي الوصول مبعدالت االنتشار والوفيات عام 2015 إىل نصف ما كانت عليه عام 1990 وإنقاذ حياة 14 مليون نسمة. ومتث ل الخطة العاملية التي شارك يف إعدادها تحالف واسع النطاق من الرشكاء أسلوبا منوذجيا يضم التدخالت التي ميكن تنفيذها بسهولة يف الواقع. أما مجاالت العمل الرئيسية التي وط دتها الخطة العاملية لدحر السل فهي: النهوض بالتدخالت ملكافحة السل وتعزيز البحوث وابتكار مواد تشخيصية وأدوات ولقاحات م ح س نة واملساهمة يف األنشطة املتعل قة بالحمالت اإلعالمية وبأنشطة التواصل واستنهاض املجتمع ملكافحة السل. وقد أ ع د ت السيناريوهات لعملية التخطيط وتتناول هذه السيناريوهات القضايا عىل الصعيد العاملي وعىل صعيد األقاليم اإلبيدمييولوجية السبعة. وقد و ض ع ت السيناريوهات افتراضات طموحة ولكنها واقعية حول رسعة النهوض باألنشطة وحول التغطية بتنفيذها كام است خ د م منوذج حسايب لتقدير أثر النهوض بالتدخالت الحالية اعتامدا عىل املعطيات التي ج م ع ت من دراسات حول بيولوجيا السل ومن الخربات حول مكافحة السل يف مواقع واسعة التباين. 346

7 Dermot Mher et l. Specil theme Tuberculosis control وقد ارتكزت التكاليف املقد رة لألنشطة التي وضعتها الخطة العاملية لدحر السل عىل تنفيذ التدخالت وعىل البحوث وعىل ابتكار األدوية واملواد التشخيصية واللقاحات وق د ر ت هذه التكاليف ب 56 مليون دوالر عىل مدى عرش سنوات أما عند ترجمتها إىل التكاليف وفق سنوات العمر املصح حة باحتساب م د د العجز التي ميكن تفاديها فإن هذه التكاليف تفوق التدخالت األخرى للصحة العمومية عند مقارنتها بها. إن هذا األسلوب من التخطيط ملكافحة السل عىل الصعيد العاملي ي عد مثاال هاما إلعداد الخطط لتحسني الصحة يف العامل والتي قد يكون لها عالقة مع القضايا الصحية األخرى. References 1. Schs J. The end of poverty: economic possibilities for our time. New York: Penguin; Esterly W. The white mn s burden: why the West s efforts to id the rest hve done so much ill nd so little good. New York: Penguin; Sen A. The mn without pln. Foreign Affirs Mrch/April Stop TB Prtnership. The globl pln to stop TB Genev: WHO; Avilble t: 5. Tretment of tuberculosis: guidelines for ntionl progrmmes. 3rd ed. Genev: WHO; Dye C, Mher D, Weil D, Espinl M, Rviglione M. Trgets for globl tuberculosis control. Int J Tuberc Lung Dis 2006;10: Stop TB Prtnership. Bsic frmework for the Globl Prtnership to Stop TB. Avilble t: 8. The world helth report 2004: chnging history. Genev: WHO; Ych D, Bettcher D. The globliztion of public helth. I: threts nd opportunities. Am J Public Helth 1998;88: Fenner F, Henderson DA, Arit I, Jezek Z, Ldnyi ID. The intensified smllpox erdiction progrmme, In: Smllpox nd its erdiction. Genev: WHO; 1988: Hopkins DR, Richrds FO, Ktbrw M. Whither onchocercisis control in? Am J Trop Med Hyg 2005;72: Jcobs L, Mrtin J-F, Godl T. A prdigm for interntionl coopertion: the Globl Allince for Vccines nd Immuniztion (GAVI) nd the Vccine Fund. In: Levine MM, Kper JB, Rppuoli R, Liu MA, Good MF, eds. New genertion vccines, 3rd ed. New York: Mrcel Dekker; Kumresn J, Heitkmp P, Smith I, Billo N. Globl Prtnership to Stop TB: model of n effective public helth prtnership. Int J Tuberc Lung Dis 2004; 8: Globl Polio Erdiction Inititive: strtegic pln Genev: WHO; Avilble t: strtpln.pdf 15. The finl push towrds elimintion of leprosy: strtegic pln Genev: WHO; 2003 (WHO/CDS/CPE/CEE/2000.1). 16. Globl strtegy for further reducing the leprosy burden nd sustining leprosy control ctivities (pln period: ). Genev: WHO; 2005 (WHO/ CDS/CPE/CEE/ ). Avilble t: GloblStrtegy.pdf 17. Globl tuberculosis control: surveillnce, plnning, finncing. WHO report Genev: WHO; 2007 (WHO/HTM/TB/ ). 18. Rviglione MC, Uplekr M. WHO s new Stop TB Strtegy. Lncet 2006; 367: Wht is DOTS? Genev: WHO; Willims BG, Grnich R, Chuhn LS, Dhrmshktu NS, Dye C. The impct of HIV/AIDS on the control of tuberculosis in Indi. Proc Ntl Acd Sci USA 2005;102: Currie CSM, Willims BG, Cheng RCH, Dye C. Tuberculosis epidemics driven by HIV: is prevention better thn cure? AIDS 2003;17: Floyd K, Pntoj A. The Globl Pln to Stop TB, : methods used to estimte costs, funding nd funding gps. Genev: WHO; Lxminryn R, Mills AJ, Bremn JG, Meshm AR, Alleyne G, Cleson M, et l. Advncement of globl helth: key messges from the Disese Control Priorities Project. Lncet 2006;367: Fifty-eighth World Helth Assembly: resolutions nd decisions. Genev: WHO; 2005 (WHA58/2005/REC/1). 25. Young D, Dye C. The development nd impct of tuberculosis vccines. Cell 2006;124: Glickmn SW, Rsiel EB, Hmilton CD, Kubtev A, Schulmn KA. A portfolio model of drug development for tuberculosis. Science 2006;311: Gndhi NR, Moll A, Sturm AW, Pwinski R, Govender T, Llloo U, et l. Extensively drug-resistnt tuberculosis s cuse of deth in ptients coinfected with tuberculosis nd HIV in rurl re of South. Lncet 2006;368: