The Union – (Way) Beyond TB
North America Regional Conference
San Antonio, 23-25 February 2012
Dr Nils E. Billo, MD, MPH
Outline
• Little history of The Union
• Beyond TB
– tobacco control and mpower
– pneumonia in children
– asthma
– operational research
– management education
• Summary
Origins of The Union
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Paris 1867: first international TB meeting
Berlin 1902: first permanent office
Paris 1920: International Union Against
Tuberculosis officially established
Paris 1986: Board decision to expand
beyond TB: adding Lung Disease to name
What is The Union?
An Institute
A Federation
• 79 Constituent Members
• 22 Organisational Members
• 2738 Individual Members
• over 30,000 contacts
• 14 Offices worldwide
• 5 Scientific Departments
Tuberculosis
Tobacco
Control
HIV
Research
Lung Health
& NCDs
The Union’s vision and mission today
Mission
The Union brings innovation, expertise, solutions
and support to address health challenges in lowand middle- income populations
Vision
Health solutions for the poor
Activities of The Union
• Founded in 1920
• Up to 1986: focus on TB: mainly Conferences,
publications, courses and technical assistance in TB
• Between 1978 and 1990: Development of the TB
DOTS strategy, mainly in Africa
• 1990s: adding asthma, child lung health, tobacco
control using TB model
• 2000-2012 adding HIV and expanding in TB and
tobacco control, adding operational research and
management education to portfolio
The Union then and today
• 1992: Staff of 12 people
Small Federation Secretariat: 1 Executive Director, 1
Scientific Director, admin staff for membership
services and Editorial office for Journal, 1 accountant
Budget 2 million USD
• From 1992 onwards: gradually growing Secretariat in
Paris with enlarged focus on Technical Assistance,
Education and Research: Institute function added
• 2011: about 250 staff and consultants in 14 offices:
Budget 50 million USD
The Tobacco Epidemic
Tobacco is the leading behavioural risk factor causing a
substantially large number of potentially preventable deaths
worldwide. The five million deaths translate to an incredible
statistic: one death every six seconds. Unless strong
actions are taken to halt the tobacco epidemic,
1,000,000,000 people are projected to die this century - we
cannot let this happen. I urge all countries to implement
fully the WHO Framework Convention on Tobacco Control.
Dr Ala Alwan, Assistant Director General , WHO,
November 2011
Proportion of TB burden attributable to
some major risk factors in high TB
burden countries
PAF 
P   R R  1
P   R R  1  1
Relative risk for
active TB disease
Weighted
prevalence
(adults 22 HBCs)
Population
Attributable
Fraction (adults)
HIV infection
20.6/26.7*
0.8%
16%
Malnutrition
3.2**
16.7%
27%
Diabetes
3.1
5.4%
10%
Alcohol use
(>40g / d)
2.9
8.1%
13%
Active smoking
2.0
26%
21%
Indoor Air
Pollution
1.4
71.2%
22%
Sources: Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis
control 2010 – 2050: cure, care and social change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.
Deaths attributable to tobacco (in %)
WHO Global Report: Mortality attributable to tobacco, 2012
Exposure to second-hand smoke
causes death and disease
Source: Office of the U.S. Surgeon General. The health consequences of involuntary exposure to tobacco smoke: a report of the Surgeon General, 2006
Bloomberg Initiative To Reduce Tobacco Use
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•
•
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Grants Programme
Capacity Building
Programme Impact 2011
Progress of The Union’s Tobacco Control work
2011
WHO MPOWER Package
monitor tobacco use and
prevention policies
protect people from tobacco
smoke (Smoke-free)
offer help to quit tobacco use
warn about the dangers of tobacco
enforce bans on tobacco
advertising, promotion and
sponsorship (TAPS)
raise taxes on tobacco
Grants programme
Capacity building
Technical and management courses since 2007
(to 31 May 2011)
Number of trainings
109
Number of participants
2305
Number of countries covered
36
Progress 2011
9 trainings held since January 2011 including 5 in March – May 2011
Total IMDP trainings in 2011 – 6
Total technical trainings in 2011 - 3
Progress in Tobacco Control
Indicator 2011
Achieved 2011
Increased Smokefree initiatives in 7 priority countries and
1 country noted for its regional influence.
China*
Indonesia
Russia*
Egypt
Pakistan
India*
Bangladesh*
FCTC compliant legislation focusing on MOPWER
interventions achieved in 2 priority countries and 2
countries of regional influence.
Russia
Indonesia*
Nepal
Lebanon
Incorporating TC into the broader health agenda in 3
priority countries.
Russia
Indonesia*
Philippines*
One recognised civil society organisation and/or
government subsidiary takes on tobacco control in 6
countries as its main area of work.
Bangladesh
Egypt
Philippines
India
Pakistan
Lebanon
* Partially achieved
Reducing childhood
pneumonia-related mortality
Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.
Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.
Child Lung Health Programme (CLHP)
MALAWI
Making a Difference in Child Survival
Specific objectives
• To standardise case management for severe and
very severe pneumonia in district hospital
paediatric inpatient ward
• To reduce mortality due to respiratory disease
especially severe/very severe pneumonia in
children under 5 years of age
• To rationalise the use of drugs for ARI in children
under 5 years of age.
• To provide uninterrupted supply of essential drugs
and oxygen at District Hospital
Enrolment into CLHP by year 2000
- 2005 n = 48,365
14000
12000
10000
24
districts
8000
Total 23
districts
6000
Total 16
districts
4000
Total 10
districts
2000
0
Total 24
districts
5 districts
2000
2001
2002
2003
2004
2005
Trend in Outcomes
1 October 2000 to 30 September 2005
Treatment completed
%
90
80
70
60
50
40
30
20
10
0
1
3
2000
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
2001
2002
2003
Months after program introduction
2004
2005
Achievements of the CLHP
Malawi
• Total number of children admitted
between October 2000-December 2005
48,365
• Baseline pneumonia CFR
18.6
• Pneumonia CFR December 2005
8.4
• Reduction over the baseline
54.8%
• Total number lives saved 2000-2005
4,357
Summary
•
Implementation of standard case management to
district hospitals is feasible and successful
•
Key elements for success are supply of drugs,
accountability and supportive visits
•
The cost is competitive, facilitating sustainability
CLHP Malawi incorporated into the Essential
Health Package
•
Adoption of Child Lung Health into National
Planning sector wide approach (SWAPS)
Why Asthma?
• Asthma is the most common chronic
disease among children.
• Asthma affects millions of adults.
• 235 million people worldwide suffer
from asthma.
• Asthma is a non-communicable
disease (NCD).
• Effective medicines are available.
• Unfortunately, for many people with
asthma – particularly the poor – these
medicines are too costly or not
available at all.
Asthma in Children
Asthma in Adults
Essential Medicines: Pricing,
Availability and Affordability
A Practical Solution:
Asthma Drug Facility (ADF)
• Provides affordable access to
quality-assured, essential
asthma medicines for lowand middle-income countries
• Promotes a quality
improvement package for the
diagnosis, treatment and
management of asthma
In countries, the cost for one year of medicines
for a patient with severe asthma can be less
than 40 USD when medicines are purchased
through ADF
ADF Clients
Countries that have already received their orders
• Pilot Projects in Benin (NTP), El Salvador (NTP),
Sudan (Epi-Lab)
• Kenya (KAPTLD)
• Burundi (NTP)
7 orders for a total of €99,826
Current orders
• Vietnam (CHDI)
• Guinea Conakry (NTP)
• Burkina Faso (NTP)
Reduction in annual costs for a patient with
severe asthma when medicines purchased
through ADF
(in euros, based on 2009/2010 ADF prices)
ADF Product Prices for 2011
Additional costs: transport, insurance, preshipment
inspection and 10% fees for ADF services
Product
Primary Supplier
(Country)
Price per unit FCA
(USD)
Beximco
(Bangladesh)
1.28
Salbutamol 100 µg/puff
200 doses, HFA inhaler*
GSK Export
(UK)
1.08
Budesonide 200µg/puff
200 doses, HFA inhaler*
Cipla/Medispray
(India)
2.60
Fluticasone 125µg/puff
120 doses, HFA inhaler
Cipla/Goa
(India)
2.50
Beclometasone 100µg/puff
200 doses, HFA inhaler*
*On the 17th WHO Essential Medicines List March 2011
Challenges at country level
• Lack of political will, other priorities
• Guidelines not available or not implemented
• Corticosteroids often not on the national Essential
Medicines List (EML)
• Non-essential medicines pushed by pharmaceutical
companies and specialists
• Lack of trained health workers
• Lack of funds to purchase essential medicines
• Restrictions in national procurement system about using
the ADF mechanism
The Economic
Burden of Asthma
Treating asthma entails vastly more than the
cost of medicines. It amounts to billions of
dollars in both direct and indirect costs.
The Global
Asthma Report
2011
www.theunion.org
http://isaac.auckland.ac.nz
www.globalasthmareport.org
Operational Research
at The Union
Centre for Operational Research
Activities
Support Bold and Innovative Strategies
MALAWI
HIV testing of all
pregnant women
and ART offered to
all those HIVpositive regardless
of CD4 count
In 3 months from April – June 2011:
509,645 persons were HIV tested
18,442 new HIV-positive patients started on ART
7524 (88%) of 8525 HIV-positive pregnant women started on ART
The DOTS Model
for monitoring
Non-Communicable
Diseases
Operational Research Fellows
• 6 Union-based OR Fellows: Malawi; Zimbabwe;
South Africa; India; Vietnam; Brazil
• 4 MOU-supported OR Fellows: South Africa (2)
and Kenya (2)
• Outputs from April 2009 - December 2011 (33 months)
55 research projects undertaken
39 completed and submitted to journals
30 papers in press or published
Operational Research Courses
Purpose: To teach the practical skills for
conducting and publishing operational research
Approach:
• Product –oriented [a submitted research paper]
• Participants go through whole research process
• Milestones must be achieved to stay in course
• Trained participants become facilitators
Three module – course starting this
week in Nepal for Asian candidates
• Module 1a: research questions, protocol
development and ethics (5 days) – February
• Module 1b: Data management and data
analysis (5 days) – February/March
• Module 2: Paper writing, peer review and
policy implications (5 days) – October
Does the Model work?
• 7 courses – either underway or completed
since 2009 - 86 participants enrolled
• 3 courses completed:– 34 participants enrolled
– 31 completed milestones /awarded certificate
– 35 papers submitted to journals
– 27 papers (>70%) in press or published
Published Papers as a result of
training / support from COR
70
60
Published Papers
50
40
30
20
10
0
2009
2010
2011
“If you do not write about it,
it did not happen”
Virginia Woolf
RESEARCH TO
POLICY
• One Expert Meeting 2009
• Two papers in IJTLD
• Two papers in TMIH
• One paper in TRSTMH
• One paper in BMC Medicine
POLICY TO PRACTICE
Bi-Directional Screening
of TB and Diabetes
Mellitus
China and India
World Diabetes Foundation Support
•National Stakeholders Meeting
•Training for implementers
•Implementation
•Review activities and data
•National Stakeholders Meeting
Strengthening Health Systems
• The Union’s International Management Development Programme (IMDP)
was created to aid countries with the difficult task of operating a national
health programme by training health managers in management education.
• Its mission is to develop a community of leaders and innovators in public
health who improve the quality of services provided to the public through
well-managed national health programmes.
Training Leaders in Public Health
• Participants who attend IMDP courses have the opportunity to become
multi-talented managers capable of dealing with complex situations in
public health that require multiple skills and competencies.
• IMDP participants generate greater value for health organisations by being
more capable of handling a variety of challenges that health programmes
face.
Summary
• Main activities in TB and
tobacco control
• Models ready to be
scaled up in child lung
health and asthma
• Operational research
critical to investigate new
areas of intervention
• Publish successes a must
• Management training and
Human Resource
Development critical
Health Solutions for the Poor
Technical Assistance – Education – Research
Union Values
• Quality
We deliver our services and products to the highest possible
standards.
• Accountability
We are responsible stewards of resources and deliver on our
commitments.
• Independence
We maintain the freedom to pursue innovation and are guided by
the best evidence to improve the health of the poor.
• Solidarity
We stand together as one Union to overcome the greatest
challenges to improve health among the communities we serve.
Thank you