Will the change in the Global Fund Disease Split reduce TB deaths?

Supporters and critics of the Global Fund Disease Split disagree

The Global Fund Board will discuss whether to keep the existing disease split or change it. The motivation behind this discussion is to decrease tuberculosis mortality. However, a change in the Global Disease split may not reduce tuberculosis mortality but may likely increase that of malaria and HIV.

Nov 3rd 2021: The Global Fund Board meeting next week will decide whether to adopt the Secretariat proposition to change the Global Disease Split to allocate more funds to tuberculosis (TB) or maintain the status quo. To divide resources the Global Fund receives from replenishment, the partnership relies mainly on estimates of the burden of disease (BOD), gross national income (GNI), and a specific formula. The current formula apportions 50% to HIV, 18% to TB, and 32% to malaria. The Secretariat proposes to use this split up to the first $11 billion, and thereafter use the distribution 45-25-30 for any other amount received beyond $11 billion.

The discussion follows a strong push led by Stop TB, drawing attention to the 1.5 million deaths attributable to TB compared to 680,000 due to HIV and about 400,000 as a result of malaria. In terms of the BOD, TB, a curable and preventable disease, affects about 10 million people: 38 million people live with HIV (PLHIV) and need lifelong treatment, and prevention against mosquito bites is needed to avert the current annual 220 million cases of malaria or provide treatment for those that have been bitten and become ill.  

A few countries account disproportionately for TB deaths: about a third of TB deaths occur in India. The majority of TB deaths among HIV-positive people occur in South Africa. Other countries that contribute the most to TB deaths are Bangladesh, China, Indonesia, Nigeria, Pakistan, and the Philippines. If approved, this change in disease split will send a political signal that the Global Fund cares about TB. But it will also move funding from HIV and malaria programs and areas with the least ability to pay compounded by the deleterious effect of COVID-19, to TB programs and areas where TB is more prevalent in mostly lower-middle-income countries who are so far experiencing fewer service disruptions from COVID-19.

Comparing TB to HIV and COVID-19

Clearly, any untimely and unnecessary death due to TB or any other disease should be avoided whenever possible. Thus, it is important to understand better why TB, the least common of the three diseases, kills more than the other two combined. In this context, there are lessons to be learned from both HIV and COVID-19.

HIV ceased to be a death sentence and became a chronic disease with the advent of antiretroviral drugs and therapies (ART). New regimens have since been rolled out, phasing out the old medicines which had more side effects. Currently, PLHIV on ART can suppress their viral load to the point that the disease is undetectable, so they cannot pass it on. HIV diagnosis can take place in the comfort of one's home and with privacy. An army of community and civil society organizations are involved with HIV prevention, treatment, and adherence efforts in most countries. Similarly, within a year, several vaccines have allowed the world to attempt to control COVID-19, and a new treatment is being piloted.

However, a TB vaccine has been available for a hundred years, since its first dose in 1921. Long treatments with unpleasant side effects are still being used. TB diagnosis has barely improved over the past decades, still needs a microscopic diagnosis, and is heavily reliant on underequipped health facilities. Thus, patients are diagnosed late, which makes successful treatment more difficult. In addition, as the treatment is long and hard to follow, many TB patients abandon it before completion, giving rise to multi-drug resistant TB.

TB needs an investment in science and more involvement of communities

The first step in decreasing TB deaths is an investment in TB-related research and development of. The fight against TB needs new and easier diagnosis tools that community health workers can use. It also needs newer and shorter regimens that will work with minimal side effects. And it needs a new vaccine for prevention as the current vaccine does not work well in adults, according to the World Health Organization 2021 Global TB report. These are not all in the Global Fund mandate but, most importantly, the change in the disease split will not address any of these needs.

Secondly, to decrease TB deaths, there is a need to involve more community systems to support earlier TB diagnosis and help those with TB to remain on treatment. The Catalytic Investments will better serve these actions, which are aimed more towards the community system than the disease programs which are usually run by governments.

How will more TB funds to countries with less TB burden result in decreased TB mortality?

Changing the Global Disease Split will give more TB money to all countries, including those that have very little TB burden. Admittedly, as the BOD counts towards the allocation of resources, countries with a low disease burden will receive relatively less of the additional resources than countries with higher burdens. Nevertheless, the global disease split will thinly spread more TB resources over all countries where the Global Fund invests. How will increased investment in Niger, for example, decrease global TB mortality?

It would be more effective to concentrate the increased funding in countries with higher mortality instead of sprinkling a little extra funding throughout all the countries where the Global Fund invests.

In addition, there is no guarantee that the change in the Global Disease Split will provide more resources to community services which are needed in most countries to make a sizeable impact in the fight against TB.

Decreasing funding for malaria and HIV will have very real consequences for the poorest

The Global Disease Split will reduce the amounts for HIV and malaria funding. While malaria mortality has indeed reduced over the last two decades, malaria morbidity has stalled. Sadly, malaria is concentrated in low-income countries and mostly those in Challenging Operating environments (COE) in West and Central Africa. Sub-Saharan African countries have the weakest post-COVID recovery, according to the International Monetary Fund (IMF). If that decrease in funding were to be implemented in a situation where countries had low absorptive capacity or with a reduced cost of health commodities, the final impact could have been balanced. Instead, the grants’ absorption rates were higher than 81% in 2019, according to the Global Fund. One of the consequences of COVID-19 has been an increase in transportation costs, making the cost of long-lasting impregnated mosquito nets (LLINs), the mainstay of malaria programs’ vector control, more expensive. (This situation calls for more LLIN manufacturing in Africa and shorter supply chains, but this discussion is beyond the scope of this article).

For HIV, grants are highly commoditized, and the fact that new infections are still high implies the need to scale-up plans that address more than expanding commodities.  

Thus, decreasing funding for HIV and malaria may increase deaths while increasing funding to TB through the proposed revised Global Disease Split may not significantly reduce TB deaths.

In summary, the net incremental effect of Global Fund investments might not reduce overall deaths.

Concentrate the funding where it is needed

Instead of changing the Global Disease Split, a better solution might be to dedicate funds to reducing TB deaths in the top 10 or so countries that contribute the most to TB mortality. Such funding would address the need to send a political message that the Global Fund cares about TB without endangering malaria and HIV programs. Those funds could be delivered through catalytic funding or any other channel that the Global Fund chooses.

In addition, the funds that the Global Fund invests in COVID-29 through the COVID-19 Response Mechanism (C19RM) could also be directed towards TB by guiding countries to purchase equipment that can serve both disease programs, like GeneXpert machines.

While it is important to address TB mortality, effectiveness and value for money also matter. The Global Fund should not inadvertently increase the burden of the other two diseases to scatter increased but diffused TB finding where it will not have the most impact.

 
Source: Aidspan