Bobby Ramakant, India: May 2011
Since its inception in 2001, the Global Fund to fight AIDS, TB and Malaria (The Global Fund) has saved approximately 5.7 million lives. Each day an additional 4000 deaths are averted, but in order to continue its existing programmes and rapidly scale up towards achieving the Millennium Development Goals (MDGs) in 2015, The Global Fund needs to invest resources in operational or applied research to confirm where it gets most value for its dollar, measured in terms of protecting human rights, saving lives and preventing infections.
For Dr Nevin Wilson, Director of the International Union Against Tuberculosis and Lung Disease (South East Asia), “After the directly observed treatment shortcourse (DOTS) model was developed by The Union) what new evidence has really been researched and put into practice. How is the Global Fund grant helping in implementing Principal Recipient (PR) to carry out the necessary operational research during the lifetime of their grant to provide the evidence that the intervention they have carried out works? This is especially true when we work with the community.”
The Union is a principal recipient (PR) of the Global Fund round 9 grant in India and is implementing one of the largest advocacy, communication and social mobilisation (ACSM) programmes in the world.
“The Global Fund round 9 grant is a very good opportunity to find and generate new evidence that some interventions work, some don’t. There can be some interventions which don’t work but still need to be funded to know that they don’t work. This is the opportunity,” adds Wilson.
He continues, “Sadly current technical review panel (TRP) mechanisms are such that if you just wrote a process to generate evidence you won’t get funded. So we just propose the intervention. Once the grant negotiation takes place we need an opportunity for the Global Fund to be flexible enough to allow PR with capacity, SR with capacity, SSR with capacity, CCM with capacity, to do the research around an intervention.”
Two third of the deaths in the world are from non-communicable diseases (NCDs). One of the common risk factors for deadly NCDs is tobacco use and diabetes, both of which increase the vulnerability of getting active TB disease. “This [operational research] involves very specific and important areas like high risk factors for TB like tobacco use in India. 300 million people in India use tobacco, their risk of acquiring TB goes up by half, risk of dying of TB goes up by half, and yet the Global Fund doesn’t do anything about tobacco. Huge populations are in India with high risk factors like diabetes, silicosis or tobacco use that collide with each other, but don’t have a coordinated response to address them,” said Wilson. To translate the knowledge around these risk factors into practice in implementation requires evidence from operational research.
Adds Wilson, “The Global Fund needs to think about how it is going to invest in current PRs, and new PRs, to generate that evidence. We need the proof of concept – start with something small and take it up to scale. We have strong national TB programmes (NTPs) now, we have community based organizations, many places in the world where the Global Fund has built capacity to implement good practices, and this is the place to put more money.”
Dr Sarabjit Chadha from The Union agrees: “The Global Fund should invest more in applied research basically to promote new vaccines, clinical trials, and new drugs. These are going to make a large difference in treatment of TB and preventing new infections. Development of new drugs which can shorten the duration of TB treatment and bring more effective cure and vaccines to prevent new infections will really go a long way in controlling the disease epidemic.”
Infection control
The other area where the Global Fund can do more on TB control is infection control. According to Dr Sarabjit Chadha, “Starting from simple things like cough hygiene, to environmental and engineering control which the Global Fund should promote in all their proposals related to control of TB. This would also mean bringing in changes in the health system, where such controls, environmental, engineering and administrative, to prevent infections are adopted by the health systems under the various governments of different countries so that they are a part of the primary, secondary and tertiary healthcare. These will also be very effective in controlling or cutting the transmission of infection and also reducing the risk to the healthcare workers.”
Dr Chadha reiterates the need for the Global Fund to expand its mandate to include co-morbidities and high risk factors associated with TB. “TB has important links with other determinants like diabetes, tobacco use, silicosis, besides HIV. While HIV-TB linkages are being strengthened very effectively, linkages with other determinants like diabetes, smoking and silicosis needs to be strengthened and the Global Fund should pay more focus to these linkages,” said Chadha.
Human rights and TB
Human rights protection in TB control is highlighted by Dr Geetanjali Sharma from The Union. She says, “We are working on increasing the reach, effectiveness and visibility of TB control programmes and our focus is to reach the special and vulnerable populations in 300 districts. We are working with special populations in 300 districts. Human rights protection for TB populations especially has not been thought in detail under the programme.”
The Patients’ Charter for TB Care is a part of the Global Stop TB Strategy but is clearly weakly implemented, if at all, at local level. The Patients’ Charter for TB Care provides a rights and responsibilities based framework for affected communities. However even this Key Correspondent couldn’t see one in evidence at a nearby TB clinic in Lucknow. “There have been instances when these marginalized populations don’t have access or they are not able to avail the services” said Sharma. There are other challenges too, as Sharma points out, “We have seen instances when they get diagnosed [with TB] but they travel long distances because they belong to certain communities and cannot have Accredited Social Health Activist (ASHA) worker or Auxiliary Nurse Midwife (ANM) belonging to other community as a DOTS provider so they have to travel all the way for services.”
The Global Fund and research
Business as usual is clearly not a choice. Innovation is a key value upheld by the Global Fund. The Fund needs to trust affected communities, and invest in research to confirm that interventions are working, and scale up those that are reaching the unreached populations.
Disclaimer: The views expressed in this note are those of the Key Correspondent and the persons interviewed by them. Whilst the material will contribute to information shared in Sao Paulo at the in-person consultation on the 2011 Partnership Forum, the material is not published as an official communication of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
