BURMA: LACK OF TB DRUGS A LOOMING PROBLEM

UNCLAS SECTION 01 OF 04 RANGOON 000279

SIPDIS

SENSITIVE
SIPDIS

DEPT FOR EAP/EX; EAP/MLS; EAP/EP; EAP/PD
DEPT FOR OES/STC/MGOLDBERG AND PBATES; OES/PCI/ASTEWART;
OES/IHA/DSINGER AND NCOMELLA
DEPT PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL
CDC ATLANTA FOR COGH SDOWELL and NCID/IB AMOEN
USDA FOR OSEC AND APHIS
USDA FOR FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG
USDA/FAS FOR FAA/YOUNG, MOLSTAD, ICD/PETTRIE, ROSENBLUM
DOD FOR OSD/ISA/AP FOR LEW STERN
PARIS FOR FAS/AG MINISTER COUNSELOR/OIE
ROME FOR FAO
BANGKOK FOR REO OFFICE, USAID/RDMA HEALTH OFFICE - JMACARTHUR,
CBOWES
TOKYO FOR HEALTH OFFICER
PACOM FOR FPA

E.O. 12958:N/A
TAGS: ECON TBIO EAID SOCI PGOV AMED BM
SUBJECT: BURMA: LACK OF TB DRUGS A LOOMING PROBLEM

REF: A) RANGOON 278 B) 07 RANGOON 1027 C) 07 RANGOON 1120

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1. (SBU) Summary. Burma is one of 22 tuberculosis high-burden
countries in the world. The Government's National TB Program (NTP),
active in all of Burma's 324 townships, reported a case detection
rate of 95 percent of all infectious cases and had a treatment rate
of 83.6 percent in 2006. The backbone of Burma's NTP is the
availability of free first line drugs for 150,000 cases, provided
free of charge from the Global Drug Facility (GDF). However, GDF's
commitment for free drugs will end in 2009, leaving Burma with no
drugs to combat the second deadliest disease in the country. The
lack of TB drugs poses a huge challenge for TB infection control in
Burma, and health experts predict that TB incidence rates, including
multi-drug resistant and extremely drug resistant TB, will increase
exponentially after 2009. The GOB is considering applying for Round
9 Global Fund assistance for 2011, but even if the Global Fund
commits to providing TB drugs to Burma, there will still be a
two-year gap in drug availability. The Japanese Government is
considering filling this gap, although has been reluctant to step in
and provide drugs without an exit strategy. End Summary.

Current State of TB in Burma
--------------


2. (SBU) Tuberculosis (TB) is a major public health concern in
Burma and the WHO classifies Burma as one of 22 TB high-burden
countries in the world. While the true prevalence of TB in Burma
remains unknown, the WHO estimates that more than 40 percent of
Burma's population is infected with TB. Some NGOs contend that up
to 60 percent of the population could be infected (Ref B). The
Ministry of Health plans to conduct a National TB Prevalence study
in 2008, although it lacks the $500,000 needed to do so. Multiple
drug resistant (MDR-TB) and extensively drug resistant (XDR-TB) TB
rates are another concern - 2003 WHO studies proved that Burma had
the highest rate of MDR-TB in Southeast Asia, with 4 percent of new
cases and 15.5 percent of previously treated TB cases testing
positive for MDR-TB. The National TB Reference Lab in Rangoon is
currently conducting a new drug resistance prevalence study.
Results should be available in late 2008, although Dr. Ti Ti,
Director of the National Reference Lab, predicted that the incidence
rate of MDR-TB is likely to be substantially higher than 2003
figures.

Public-Private Partnership
--------------


3. (SBU) Through its National TB Program (NTP),which is active in
all 324 townships in Burma, the Burmese Government seeks to treat
and prevent TB throughout the country. The State and Division

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Health Departments are responsible for planning, coordination,
training and technical support, and monitoring of health services on
the state and division levels. According to NTP Director Dr. Win
Maung, township-level TB officers provide the actual health services
to the people, including dispensing free TB drugs to patients and
monitoring the patient's treatment. In 2006, the NTP had a case
detection rate of 95 percent of all infectious cases and a treatment
rate of 83.6 percent in 2006, which exceeded WHO targets for
combating TB. Burma also has two TB hospitals, Aung San Hospital in
Rangoon and Pathengyi Hospital in Mandalay, that provide treatment
for the more challenging TB cases, including MDR and HIV/TB
co-infection cases.


4. (SBU) NTP activities are supplemented by services provided by
private clinics, including those run by Population Services
International (PSI),the Myanmar Medical Association, and Medecins
Sans Frontieres-Holland (MSF-H). PSI has clinics throughout the
country, with 415 private doctors providing TB Directly Observed
Short Course (DOTS) treatment in 100 townships. MSF-H runs 24
full-service medical facilities in six states and divisions, and MMA
has 526 doctors providing DOTS treatment in 23 townships throughout
the country. Not all of these clinics provide the same services,
although all will see and diagnosis TB patients. PSI clinics treat
TB patients directly, providing free TB drugs to patients, as well
as conducting monitoring to ensure that patients complete the TB
treatment protocol. MMA clinics refer TB patients to local NTP
clinics for treatment. MSF-Holland also refers basic TB cases to
the NTP, but will treat more difficult TB cases, specifically TB/HIV
co-infection cases.


5. (SBU) TB treatment in both the NTP and in private clinics
follows the Directly Observed Treatment Short Course (DOTS). Under
the DOTS program, which was established with WHO assistance in 1994,
a community or health care worker directly observes the patient
swallowing their anti-TB medications over a six month period. The
NTP provides TB drugs (provided by Global Drug Facility) to both
public and private clinics and requires that clinics keep detailed
accounts of treatment for each patient. Clinic doctors either
monitor the patients directly or work with community volunteers and
family members to ensure that the patients follow the treatment
protocol.

Securing Access to TB Drugs
--------------


6. (SBU) The backbone of Burma's TB program is the free drugs
provided to TB patients. The Global Drug Facility (GDF) currently
is committed to providing first line TB drugs to Burma through the
end of 2009. The NTP each year receives DOTS protocol treatment for

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approximately 150,000 TB patients and distributes them through the
NTP and PSI/MSF-H clinical sites. The drugs are worth an estimated
$4 million a year. As the GDF commitment comes to an end, the
Ministry of Health, WHO, and the private sector are scrambling to
secure TB drugs for future years (Ref A). The Burmese Government is
unwilling to purchase these drugs directly, and the Ministry of
Health, with its annual TB budget of $400,000 in FY2008, is unable
to reallocate funding for first-line TB drugs.


7. (SBU) Instead, the Ministry of Health is looking toward
alternate providers of TB drugs, namely the Global Fund.
Representatives from the Global Fund met with the Minister of Health
in late March and encouraged him to submit a new application to the
Global Fund, 3 Diseases Fund Manager Mikko Lainejoki told us. While
the senior generals are leery of the Global Fund after its abrupt
departure from Burma in 2005, MOH officials told the 3D Fund and WHO
representatives that the Burmese Government was considering
submitting an application for Round 9, which would begin in 2011.
However, even if the GOB secured a commitment from the Global Fund
to cover first line TB drugs, there would still be a two-year gap in
drug coverage. This gap could create a dangerous situation in
Burma, WHO Tuberculosis Officer Dr. Hans Kluge underscored. The
rate of TB infection would increase dramatically and people would be
forced to buy inferior TB drugs on the local market. If people do
not complete the TB treatment and stop taking the drugs the minute
they feel better, they could develop and spread MDR-TB, he stated.

Filling the Gap
--------------


8. (SBU) Recognizing the lack of TB drugs could pose both a
domestic and regional problem, the Japanese Government is
considering providing funds to cover the gap. Masashi Ogawa,
Economic Counselor at the Japanese Embassy, warned us that the
Government of Japan support was not a forgone conclusion because
relations between Japan and Burma cooled considerably after the
shooting of the Japanese reporter in September. The Japanese
Government plans to reduce humanitarian assistance to Burma by
one-third in 2008, so funding TB drugs may be politically
challenging, he underscored. If the Government of Japan agreed to
provide TB drugs, it would only be for a few years, rather than long
term. Ideally, Japan would provide approximately $4 million in
funding for 2010 after the Burmese Government agreed to apply for
Round 9 of the Global Fund. The last thing Japan wants is to start
funding the program with no exit strategy, Ogawa stated.


9. (SBU) During our two-week assessment of Burma's current TB
situation, we found that most donors were confident that the
Japanese would provide funding to cover the gap period, although

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they understood the political challenges facing the Japanese
Government. In the meantime, the WHO plans to encourage the GDF to
extend its program an additional year, although Dr. Kluge told us
that this was unlikely because the GDF had already extended its
program in Burma by one year. While some NGOs mentioned that the 3D
Fund may shift resources to cover drugs, 3D Fund TB Officer Atila
Molnar stressed that the 3D Fund did not have enough funds to cover
the gap. Additionally, the 3D Fund's mandate is to strengthen
health care services at the township level; he doubted the 3D Fund
Board would agree to divert resources from the local level to cover
the cost of TB drugs. There are only two options, Molnar declared:
either the Japanese Government covers the gap period or the Burmese
Government puts additional resources toward procuring drugs. Since
the second option is unlikely, he stated, donors will continue to
pressure the Japanese to fill the gap.

Comment
--------------


10. (SBU) During USAID's two-week assessment of Burma's TB program,
we learned that the NTP faces many challenges in combating and
preventing the spread of TB both inside and outside of Burma (Ref
A). However, officials from the Ministry of Health, NTP, 3D Fund,
WHO, and NGOs all agreed that the most immediate challenge facing
both the public and private sector is securing access to first-line
TB drugs after 2009. A solid first-line drug regimen is the
backbone of Burma's TB program and is vital to preventing the spread
of TB, including multi-drug and extensively drug resistant TB.
Certainly, the Burmese military regime, with more than $2 billion in
annual oil revenues, should be funding these, but it won't.
Therefore, we should encourage the Japanese Government, the only
donor who is able to procure drugs, to fund Burma's first-line TB
regime for 2010 and beyond. Once long-term access to drugs is
secured, the NTP and the private sector can begin to address other
challenges, including strengthening case detection and treatment,
building capacity at the national labs, and improving infection
control.

VILLAROSA