A Presentation on USAIDs TB Programs

Irene Koek Chief Infectious Disease/Environmental Health Division USAID

Thank you. It is an honor to be here and to speak to all of you today. I am also very pleased to see participants here from around the world bringing together all of us concerned with moving forward an important agenda. Effective drug management is clearly an important issue not only for countries currently receiving TB drugs from the Global Drug Facility, but also for those that will be procuring them or receiving them from different sources in the future. Id like to talk to you today about the importance of drug management to effective TB efforts, and to describe briefly USAIDs TB programs and our work in improving drug management. Drug management issues continue to be a major obstacle to improved TB programs contributing to the huge mortality burden of TB. These issues include

Poor access to high-quality TB drugs Irrational treatment decisions and behaviors Inappropriate forecasting Inadequate infrastructure Inadequate financial resources

Poor availability and access to first-line TB drugs have resulted in treatment interruptions in many developing countries, often impeding DOTS expansion and creating the conditions for the emergence of drug resistance. Drug availability problems have sometimes been caused by financial constraints, but the lack of drug management skills and capacity and availability of local staff managing DOTS programs has also been a major contributing factor. The link between poor access to vital TB drugs and weak pharmaceutical systems in which managers are poorly trained cannot be overemphasized. With the escalating HIV/AIDS epidemic and the critical link between TB and HIV/AIDS, the need for a reliable supply of TB drugs of assured quality, readily available to those in need, becomes even more imperative. It is a fundamental premise of the Global Plan to Stop TB that national governments and local communities take responsibility for planning and implementing their TB-prevention and treatment programs. This does not mean, however, that each country has to face its TB problem

TB Drug Management Workshop

in isolation. USAID and other donors have developed initiatives to help address all aspects of the DOTS strategy at both global and local levels. Let me say a few words about USAIDs TB program. USAID is committed to addressing the global burden of TB in close collaboration with developing country, regional, and global partners. In 1998, as part of a new strategy expanding USAIDs efforts in infectious and reemerging diseases and with additional funding, USAID began to develop a significant and focused program in TB. Since then, resources available for TB have increased each year. This year, USAID will spend $65 million on international TB in addition to the U.S. governments contribution of $200 million to the Global Fund for AIDS, TB, and Malaria. As a member of the Stop TB partnership, the heart of our strategy is focused on working with key countries to expand the application of the DOTS strategy. We are currently working in more than 20 countries. In addition to working with many of you at the country level, our major partner in this effort is the TB Coalition for Technical Assistance led by KNCV. Stop TB and KNCVthe organizers of this workshopare two of our most important partners. We are also providing direct support to the Stop TB Initiative at the global and regional levels. The Stop TB Initiative has done an outstanding job mobilizing attention and resources on the problem of TB. Recognizing at the outset the importance of drug management to achieving objectives related to DOTS expansion, the Initiative launched the Global Drug Facility last year. The GDF has already become an important tool in our efforts to improve TB control. Other key elements of USAIDs TB strategy include

Expanding the cadre of TB experts

Supporting key research such as operations research to improve approaches to DOTS and the development of an inexpensive, field-appropriate diagnostic

Monitoring and evaluation, including support for the WHO TB surveillance

system In the future, we also hope to work more closely with the NGO/PVO community and facilitate the partnering of these organizations with the leading TB partners. At USAID, we also recognize how critical drug management systems are to the success of any program that includes large (or small) amounts of pharmaceuticals. Such systems must be strengthened and anchored in local capacity to complement the arrival of increasing amounts of pharmaceuticals and other health commodities being sent to countries around the globe. Investing in improved pharmaceutical management has long been a very important part of USAIDs health portfolio. As part of our support for DOTS expansion, USAID has given significant priority to improving drug management.

Annex 4. Plenary PresentationsUSAIDs TB Programs

USAIDs major mechanism for providing drug management support to TB programs worldwide is the Rational Pharmaceutical Management Plus Program (RPM Plus), which provides technical assistance and a systems approach to assisting countries interested in improving their pharmaceutical management systems. The RPM Plus cooperative agreement was awarded to Management Sciences for Health (MSH), one of the sponsors of this workshop. Management Sciences for Health is an acknowledged worldwide leader in the area of drug management. Concerned about improving the availability of TB drugs of assured quality, MSH has provided technical support to Stop TB and the Global Drug Facility by way of the SEAM (Strategy for Enhancing Access to Medicines) project, a Gates Foundationfunded initiative. This support has included identifying important quality assurance issues and procurement and supply management options for the GDF, and supporting the secondment of a procurement/drug management specialist to the GDF. The USAID-funded RPM Plus Program has become a major player and collaborator with global TB partners. Several of its activities that are worthy of note include Developing TB drug procurement training materials in partnership with KNCV and the TB Coalition, and regional and country-specific TB procurement training workshops

Designing a Drug Management for TB diagnostic assessment tool

Participating in numerous training workshops for TB program managers and consultants by conducting the drug management sessions Conducting a study on the use of incentives for DOTS compliance, with WHO and the World Bank

Participating in country TB assessment visits with the GDF and the TB Coalition

According to its mandate, the GDF delivers TB drugs to the border of the countries that have been approved as recipients. Therefore, even greater attention must be given to the element of the DOTS strategy concerned with ensuring an the uninterrupted supply of TB drugs. Fortunately, in recent years this element has been receiving increased attention. As evidenced by this workshop, global TB partners have recognized the importance of drug management to ensuring an uninterrupted supply of TB drugs. This workshop is an excellent example of the improved international environment, which seeks to give adequate attention to the critical role of reliable drug supplies for effective DOTS program implementation. With the establishment of global initiatives such as the Global Drug Facility and the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), there is a critical need for technical leadership and concrete measures to address drug management concerns and issues.

TB Drug Management Workshop

The challenge is to take maximum advantage of the increased resources these global initiatives bring to the table. We must quickly develop enhanced local capacity and systems to manage and use drugs appropriately, and ensure that drug resistance does not require the use of more expensive drugs and much longer or complicated treatment options. This workshop is a watershed event in the international effort to provide a coordinated and adequate response in support of effective TB control programs. The GDF is a symbol of successful global coordination in a world where global initiatives and public-private partnerships are becoming a new formula for health programming. Hopefully, those developing other global initiatives will continue to learn from your experiences by ensuring that funds are set aside for investment in technical assistance and human capacity-building to improve drug management systemswhich are such an integral part of a functioning health care system. Given the tremendous impact of HIV/AIDS on the struggle to combat TB, and the reality that large-scale supply of commodities for the diseases of HIV/AIDS, TB, and malaria are likely to significantly increase in countries around the world through the various global initiatives, there could not be a more opportune moment for the world pharmaceutical and TB leaderssuch as yourselvesto be gathered together in an effort to address the weaknesses of drug management systems in countries that will be, or already are, receiving drugs. The present meeting indicates the increased recognition that TB drug management now plays in TB control. It is thus not by chance that the TB Drug Management meeting immediately follows the World TB Congress. I look forward to hearing the suggestions and possibilities that come out of the working group sessions over the next three days. Thank you again for inviting me and my USAID colleagues to participate in this exciting workshop.