March 28, 2000
HEADLINE: India: TB threatens development
Excerpts from an address to the Ministerial Conference on Tuberculosis and Sustainable
Development, in Amsterdam, convened by the World Health Organisation and the World Bank.
A WORLD free of poverty will remain a mere dream unless we join hands to overcome major
global threats to the poor and marginalised people around the world. Without question,
tuberculosis (TB) is one such threat, and its control must be at the core of the global
development agenda.
Of the 20 million people affected by TB today, about 95 per cent live in the developing
world. Of all the developing regions, South Asia has the greatest number of people with
TB. This is also the region that harbours the greatest number of the poor and the majority
of the world's children.
Investing in TB-control programmes makes economic and development sense at several
levels. TB and poverty are linked. Poor living and working conditions stimulate
transmission and disease, and disease exacerbates economic and social distress. Worse, TB
and its association with HIV/AIDS compound the poverty cycle.
This combination increases the burden on health finance, and severely strains public
finance, forcing hard trade-offs. In India, for example, the average annual treatment
expenditure on one HIV/TB case costs more than educating 10 primary school students. We
have to act now without delay before we face more dire conditions.
Over the last few years, the World Bank has conducted participatory research and
listening engagements with 60,000 poor people in 60 countries.
The first results have just been published in a volume The voices of the poor: Can
anyone hear us?. These voices confirm that the critical missing link between poverty and a
life worth living is personal security - especially freedom from disease.
More than anything else, it is the illness of the bread-winners that pushes families
into poverty. Even more than education, they said, it is diseases such as TB that prevent
them from helping themselves out of poverty.
Traditional strategies can no longer cope with the impact on national economies and
societies that TB, drug- resistant TB, and HIV/AIDS cause. Fortunately, we do have the
means to alter TB's course. The Directly-observed Treatment Short course (DOTS) public
health strategy is the cornerstone of this action.
But for such a strategy to stop TB, it must be an integral part of poverty-reduction
strategies in every developing nation - strategies that reflect the country's own
convictions and political will, and strategies that are supported by the international
community.
There are five principles to help developing nations improve their public policy and
investment in the battle against the epidemic.
First, consider TB control as a global 'public good', not just a national one. Benefits
accrue to all citizens of the world, not just to those treated and cured in any country.
Without a sound public health policy, regulation, and investment, health-care providers
tend to offer too little care, and patients tend to seek too little. Without generating
and sharing knowledge on the epidemic or on new strategies and technologies, all nations
are threatened, regardless of national borders.
Second, invest more, and wisely, in efficient and effective health policy, regulation,
and systems that serve all citizens with equity.
Without greater and more strategic investment, improvements in health outcomes,
including TB, cannot be realised.
Nor can countries expect to raise visibly access to quality services for poor people,
hard-to-reach patients, HIV- positive TB patients, and those ill with drug-resistant
disease.
Third, establish public-private partnerships. Fighting TB and other global threats
cannot be undertaken by the government alone. Public-private partnerships are critical to
this effort. Private providers are significant players everywhere, including in the
developing world. In South Asia, for example, more than half the population turns first to
private providers when ill.
Everyone will benefit from a paradigm shift in both public and private care quality,
and the dove-tailed partnerships between them. Such partnerships must also go beyond
care-providers, to civil society at large that offers huge untapped potential in fighting
TB.
Fourth, erase gross inefficiencies and invest in best practices and new tools. There is
no room for tests and treatments that waste the precious time and the resources of the
patients and society.
There is every room for interventions that make prevention and cure affordable, easy,
and fast. We also need more communication to encourage patients to seek early and complete
care, and to health-providers to do what is right.
Fifth, maintain prudent fiscal policy and quality public expenditure, as the potential
burdens on health finance alone, and on public finance altogether, are likely to be
significant.
In many countries, there has been demonstrable progress in TB control.
But there are still many areas where such progress remains elusive.
Partnerships is at the heart of our success. But it must be a partnership rooted in the
strength of each nation's conviction and will to act.
This must start at the top, with the political leadership, and permeate all levels of
civil society. Focussing the might of leaderships everywhere on the problem and
orchestrating all the change agents throughout society is at the heart of the solution.
Mieko Nishimizu
(The author is World Bank Vice-President, South Asia Region.)