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 RANGOON 00000279 001.2 OF 004 ¶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 RANGOON 00000279 002.2 OF 004 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 RANGOON 00000279 003.2 OF 004 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 RANGOON 00000279 004.2 OF 004 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