Thailand - Stop TB Partnership

High-level political commitment?
The adoption of the Amsterdam Declaration to Stop TB in 2000 marked an important
milestone in the attempt to muster high-level political commitment to a reinvigorated global
TB control effort. Governments of the countries with the highest burden of TB pledged
to expand access to the WHO-recommended DOTS framework for TB control in their
countries; 2 to ensure sufficient human and financial resources to support implementation;
to monitor and evaluate their national TB programs in line with WHO standards; to ensure
“quality, access, transparency and timely supply” of TB drugs; and to support partnerships
with NGOs and the community. 3
However, rhetorical commitment to the Declaration has not been reflected in adequate
budgetary allocations at the national and subnational levels. Without strong national
leadership, state and local officials are less likely to give budgetary priority to either TB control,
particularly in highly decentralized political systems as in Brazil and Nigeria, or health
care reforms, as in Tanzania and Thailand, where cost-cutting measures have had a dramatic
impact on the capacity of national TB programs, particularly with regard to monitoring and
evaluation, staffing, and training.
Underfunding of the health sector in general has compromised capacity to treat TB
within existing public health systems in Bangladesh, Nigeria, and Tanzania. The executive
director of Nigeria’s National Primary Health Care Development Agency commented that
“where [primary health care] services are available, the quality is such that people prefer
to go elsewhere for the services.” 4 Public Health Watch researchers from all five countries
judged that government spending on TB was inadequate to ensure the effective implementation
of national TB policies. For example, only about two-thirds of all Bangladeshi laboratories
have the capacity to perform high-quality smear tests, 5 and laboratory rooms in some
subdistricts are small and poorly ventilated, creating health risks for staff. As researcher
Afsan Chowdhury noted, “If you measure political commitment [in Bangladesh] in terms
of resource mobilization—if you see this as a measure of the extent to which TB is on the
political agenda—it’s low, there’s not much.” 6 TB workers are underpaid and overworked,
leading to high turnover, sagging morale, and low recruitment. As funding for TB control
has declined in Brazil over the past few decades, so has the prestige of TB work, even as
increased investment in HIV/AIDS since the early 1990s has helped enhance the status of
HIV/AIDS workers.
In Brazil, Nigeria, Tanzania, and Thailand, the HIV/AIDS epidemic has fueled a
dramatic resurgence in TB rates and put an additional strain on health infrastructures, yet
governments have been slow to respond with corresponding increases in TB budgets and
personnel. In Tanzania, the resurgence in TB rates—a six-fold increase in the number of
cases between 1983 and 2003—has largely been attributed to the HIV epidemic. HIV preva-
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TB POLICY IN THAILAND