Recent review of the strategic plan to end TB reveals that there are emerging needs to enhance key interventions to scale up active case findings to cover large proportions of targeted populations while using sensitive, cost-effective and efficient approaches
Tuberculosis (TB) is increasingly considered as a public health scourge, a health security threat and development challenge. Though it is preventable and curable, evidence suggests that TB was a second leading cause of death yet in 2022 from a single infectious disease after COVID-19, and caused almost twice as many deaths as HIV and AIDS.
Given this ground reality, the TB epidemic is more serious in low- and middle- income countries. In the recent years, TB is largely considered as a social disease as it has several differential effects on the lives of poor and socially marginalised populations who are in their most productive ages. Moreover, TB is perceived as a disease of poverty, and its wider socio-economic impacts on individuals, families and communities are profoundly adverse. Undoubtedly, it causes prolonged socio-economic distress, marginalisation, stigma and discrimination in the families and health care settings.
Nepal still has a heavy burden of TB with an estimated incidence of 69,000, as per the first ever TB prevalence survey in 2018/19. The estimated TB prevalence and incidence are 416 and 245 per 100, 000 people, respectively. Sadly, majority of the TB patients are in their productive ages (15-55). Moreover, the TB prevalence among men is more than in women.
Again, the drug-resistant TB is a serious challenge in TB response. Even after full treatment of TB, many people still suffer disability. The worrying part is that a large proportion of the people with TB are missed by the TB programme either because they are not diagnosed or not reported when diagnosed.
In order to confront the burden of TB, Nepal's strategic plan to end TB (2021/22-2025/26) largely aims to strengthen patient-centered care and prevention, enhance bold policies and supportive systems to address the social determinants of TB, and tackle the emerging risks and vulnerabilities among people who are very poor, socially marginalised such as people living with HIV, migrants and so forth. In addition, the strategy sheds light on critical needs to intensify operational research for the design, implementation, and scaling up of the innovative interventions.
In this context, Nepal is embarking on an exciting journey with its TB free initiative. The overarching aim of this initiative is to enhance the role and accountability of local governments in the fight against TB. We stand at a crossroads as Nepal is committed to Universal Health Coverage (UHC) and Sustainable Development Goals (SDGs) for 2030.
However, we need multi-sector actions to make the initiative a reality by targeting people who are most affected by it: the poorest, socially marginalised and inequitably served. Therefore, effective implementation of the UHC is critical along with the provision of social protection services to empower people with TB and their families for their overall social well-being and dignified lives.
Additionally, the TB free Nepal initiative is considered as an ambitious and innovative strategy to end the TB epidemic by 2035. It is being implemented in 25 of the 753 local levels, and has now been scaled up in an additional 100 local levels from this fiscal year. In the federal context, local health systems are consistently facing diverse challenges in ensuring adequate human resources for health, essential equipment and good health infrastructure, regular supplies of drugs and laboratory consumables, robust monitoring and reporting practices for tracking the progress.
Moreover, pandemics such as COVID-19 and other natural disasters significantly increase vulnerabilities to TB and limit the ability of local health systems to provide quality TB prevention, treatment and care services. Therefore, effective implementation of the TB free initiative is still a key question as there still lacks coordinated and coherent actions across federal, provincial and local governments.
Despite the technical support from external development partners, Nepal needs to mobilise additional resources to address the programmatic gaps for achieving wider service coverage. For this, Nepal should effectively regulate a multi-sectoral accountability framework for better coordination and collaboration with a range of relevant stakeholders beyond the health sector
Recent review of the strategic plan to end TB reveals that there are emerging needs to enhance key interventions to scale up active case findings to cover large proportions of targeted populations while using sensitive, cost-effective and efficient approaches.
Considering the emerging challenges of climate change, migration, and socio-political and economic transition, the TB epidemic imposes a high socio-economic burden on the country as it is mostly concentrated in young adults. Issues of gender inequality, social exclusion, stigma and discrimination in the communities have profound impacts on people's vulnerabilities to TB and HIV co-infections, and their access to prevention, treatment and care. Therefore, it is necessary to consider socio-cultural, economic and political determinants of TB for ensuring a holistic approach in the fight against the epidemic.
In addition, the role of communities and civil society is critical for sustained TB response. Therefore, the importance of community and civil society engagement to end TB has been highlighted in various strategies and global commitments. Furthermore, the political declaration of the 2023 United Nations High-level Meeting on TB highlights the need to ensure people-centered health services, with meaningful engagement of communities to harness a coordinated TB response. Undoubtedly, Nepal has a long way to go for meeting the challenge of ending the epidemic by 2035.
Bhandari is a health policy analyst
