Trade, foreign policy, diplomacy and health

3. Tuberculosis control

Jim Yong Kim, Aaron Shakow, Arachu Castro, Chris Vande, Paul Farmer

TB control as a Global Public Good for Health

  • TB-control as a classic example of a GPGH
  • Each infectious patient infects 25-50% of contacts. Benefit of reducing this is:
  • non-rivalrous: all can benefit equally
  • non-excludable: none prevented from benefiting
  • TB control displays
  • ‘weak link’ characteristics
  • ‘prisoner’s dilemma’
  • ‘free riders’

The CMH, and UNDP, have presented TB-control as a classic example of how a health program might be considered a global public good. Although the patient receives the private good of being cured of the disease, a patient cured of TB is one less person contributing to the continued spread of the epidemic: it is estimated that each infectious patient infects 25-50% of his household contacts. In this instance we have a benefit that is both non-rivalrous (each person can benefit from the reduced risk of infection without impacting another’s risk of infection) and non-excludable (reduced environmental exposure affects everyone in the community and none can be excluded). In this sense, the overall control of TB has GPGH characteristics.

Some may interpret the provision of TB treatment as a club good—that TB treatment is an attainable product for those nations and individuals willing and/or able to pay for TB control services. Such arguments have dominated international public health throughout the antibiotic era. However, as barriers to travel have come down, and drug resistance and HIV/AIDS thereaten the efficacy of treatment, developed countries are being forced to look at more ‘upstream’ solutions. As a GPGH, TB control displays “weak link” characteristics – with globalization, the maximum attainable level of control in any particular country can be impacted by the level of control achieved in the worst national TB control program. TB control also suffers from “prisoner’s dilemma” issues in that countries must make the decision to invest in TB control while not knowing if neighbouring countries will do the same. In some instances, certain countries could become ‘free riders’ by ignoring their own TB problems and leaving patients to seek care privately or in other countries that offer free, high-quality services.