1. GLOBAL TB PROGRAMME Knut Lönnroth Global TB Programme, WHO Monitoring social protection Sickness insurance Food package Disability grants Other welfare grants Travel vouchers MechanismsOutcomes Case detection % with catastrophic cost Treatment outcome Access to social protection interventions for TB patients Housing support Other cash transfer Situation assessment Monitoring of coverage and outcomes Job security

2. GLOBAL TB PROGRAMME Proposed key indicators Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention. PLoS Med 2014; 11(9): e1001693

3. GLOBAL TB PROGRAMME TARGETS 35% reduction in TB deaths 20% reduction TB incidence rate (<85/100 000) No affected families with catastrophic costs due to TB TARGETS 75% reduction in TB deaths 50% reduction TB incidence rate (<55/100 000) No affected families with catastrophic costs due to TB TARGETS 90% reduction in TB deaths 80% reduction TB incidence rate (<20/100 000) No affected families with catastrophic costs due to TB GOAL 95% reduction in TB deaths 90% reduction TB incidence rate (<10/100 000) No affected families with catastrophic costs due to TB 2035 202020302025 Milestones in WHO's post-2015 global TB strategy

4. GLOBAL TB PROGRAMME Post-2015 Global TB Strategy

5. GLOBAL TB PROGRAMME Mean cost as percentage of annual individual income Higher cost among: People with MDR-TB People from low socioeconomic groups Source: Tanimura T, Jaramillo E, Weil D, Raviglione M, Lönnroth K. Financial burden for tuberculosis patients in low- and middle-income countries – a systematic review. ERJ 2014

6. GLOBAL TB PROGRAMME Composition of TB related costs, on average During treatment 50% of total costs Before treatment 50% of total costs UHC

7. GLOBAL TB PROGRAMME Coping mechanisms % taking lone % selling household items % using own savings % transfers from relatives Myanmar, Urban, 2004,55.3% India, Rural, 2000,71% Thailand, Nationwide, 1996/97, Income below poverty line12%16%22%23% Thailand, Nationwide, 1996/97, Income below average9%7%21% Thailand, Nationwide, 1996/97, Income above average8% 14%17% India, Urban & Rural,, government76% India, Urban & Rural,, NGO58% India, Urban & Rural,, private urban68% China, Rural, 2002-2005,8%45% 66% Ghana, Urban & Rural, NA,47%37% Viet Nam, Urban & Rural, NA,17%5% Dominican Republic, Urban & Rural, NA,45%19% Tajikistan, Urban & Rural, 2006/07,30%49%30%

8. GLOBAL TB PROGRAMME Definitions WHO definition of UHC: a)universal access to needed health services; b)without financial hardship in paying for them (i.e. concerned with out-of-pocket medical expenses only) WHO definition of "catastrophic health expenditure”: Direct health care expenditures corresponding to >40% of annual discretionary income" (income after basic needs, such as food and housing). (i.e. indirect costs of care and income loss are not included). ILO definition of social protection: a)Access to Essential Services (water and sanitation, health, education, etc); b)Essential Social Transfers (cash and in kind, paid to the poor and vulnerable)  To enhance food security and nutrition,  To provide a minimum income security and access to services  Income replacement and social support in the event of illness

9. GLOBAL TB PROGRAMME The three dimensions of UHC

10. GLOBAL TB PROGRAMME UHC with added protection for non-medical costs of illness & care Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention. PLoS Med 2014; 11(9): e1001693

11. GLOBAL TB PROGRAMME Knut Lönnroth Global TB Programme, WHO Sickness insurance Food package Disability grants Other welfare grants Travel vouchers MechanismsOutcomes Case detection % with catastrophic cost Treatment outcome Access to social protection interventions Housing support Other cash transfer Situation assessment Monitoring of coverage and outcomes Job security Monitoring framework

12. GLOBAL TB PROGRAMME Proposed key indicators Lönnroth K, Glaziou P, Weil D, Floyd K, Uplekar M, Raviglione M. Monitoring universal health coverage and social protection in the context of tuberculosis care and prevention. PLoS Med 11(9): e1001693

13. GLOBAL TB PROGRAMME Definition of catastrophic cost - options: 1.Total cost as percentage of annual household income (over a defined level)  Requires collection of direct and indirect cost data plus income data  Possible cut-off:  >20% (which is associated with poor treatment outcomes, Wingfield et al, 2014)?  >10% (judged to have important financial implications, at least for poor families)? 2.Any occurrence of important "Dissaving"  Requires much simpler questions about potentially irreversible coping mechanisms:  Taking out a loan  Selling property/livestock/household items  Associated with total cost and total cost as percentage of income (Madan et al, 2014)

14. GLOBAL TB PROGRAMME Data collection approaches 1.Routine surveillance data from TB register (monitoring access to social protection only) 2.TB patient survey (diagnosed cases) 3.TB prevalence surveys 4.Health expenditure subaccount for TB (too small sample probably)

15. GLOBAL TB PROGRAMME The patient cost tool Generic survey instrument with tools for country adaptation (KNCV, WHO and JATA, 2010) Built on rich previous research Study population: people diagnosed with TB Recently adapted to people with MDR-TB Domains –Health seeking (provider utilization, delay) –Direct cost for diagnosis, treatment, transport, etc –Indirect costs (income loss) –Social consequences (divorce, interrupted education, etc) –Coping mechanisms (loans, selling goods, etc) –Patient characteristics (age, sex, socioeconomic status, etc) –Access to social protection

16. GLOBAL TB PROGRAMME Where and how often? Sample: National random samples? Sentinel sites? Frequency: Every 5 years? More often? Global monitoring: Baseline in 2015/16 All countries or panel of countries? Every year? Every 5 years?

17. GLOBAL TB PROGRAMME Next steps Further methodological development  Planned meeting on social protection interventions and monitoring, tentatively March 2015  Including meeting task force on monitoring social protections Demonstration studies in selected countries in all regions  Select 2-3 countries in WPR? Continued support to countries so that baseline can be established for 2015-2016  All WPR priority countries?