The World Health Organization multisectoral accountability framework to end TB (MAF-TB): progress and way forward

Tuberculosis (TB) is strongly influenced by social and economic determinants. Factors such as poverty, undernourishment, and poor living and working conditions, among others, affect the risk of being infected with TB and, once infected, the risk of developing TB disease. They also affect how people who fall ill with TB disease are able to cope with the demands of treatment (including medical, financial and social aspects) and in turn their treatment outcomes. Addressing these broader determinants requires multisectoral action and accountability.

The political declaration from the 2023 United Nations (UN) high-level meeting on TB (1) includes commitments to strengthen multisectoral action and accountability, including through use of the World Health Organization (WHO) multisectoral accountability framework (MAF-TB) (2).

The MAF-TB has two major parts: one for the global/regional level; and one for the national/subnational level. Each part has four major, inter-related components: commitments; actions; monitoring and reporting; and review.

The MAF-TB is also prioritized in the WHO Director-General’s flagship initiative to end TB for the period 2023–2027 (3).

Global level

In line with the global part of the MAF-TB, WHO continues to lead the coordination of global monitoring, reporting and review, and to provide technical support and guidance to countries and partners through a collaborative global multisectoral and multistakeholder platform on ending TB (4). The platform engages UN agencies, civil society and affected communities, and other key partners. It provides a forum for discussion and facilitates systematic and timely dissemination and exchange of information among key stakeholders. For example, members of the platform met in advance of the second UN high-level meeting on TB in July 2023, to discuss how to provide guidance and support to countries in their preparations for the meeting and to outline key priorities in operationalizing commitments.

To support Member States in MAF-TB adaptation and implementation, WHO released two new documents in 2023: one provides guidance in how to operationalize the MAF-TB (5) and the other is a compendium of best practices (6) (Fig. 1).

The operational guidance provides practical advice on key approaches and interventions needed to establish the MAF-TB at national and local levels, organized as 10 main steps (Fig. 1) that are illustrated with country examples, best practices and case studies.

The best practice document features case studies from Armenia, Belarus, Brazil, Cambodia, China, the Democratic Republic of the Congo, India, Kenya, Pakistan, the Philippines, the Russian Federation, South Africa, Thailand, Ukraine and Viet Nam as well as a group of 12 countries in francophone Africa. The roles of UN agencies, partners and civil society are also highlighted as case studies.

WHO continues to advocate for scaling up the MAF-TB through a variety of events and forums.

Fig. 1 Main steps for MAF-TB adaptation and implementation

MAF-TB: multisectoral accountability framework to end TB.

National level

To facilitate strengthened accountability at national level, WHO continues to provide technical assistance to countries to perform baseline MAF-TB assessments using the WHO checklist (7), to undertake programme reviews and to develop national strategic plans for TB. Support has also been provided for national consultations, the development of multisectoral coordination and review mechanisms, and legislative, regulatory and other measures to scale up MAF-TB implementation at country level.

Since 2020, WHO has been collecting data for selected MAF-TB-related indicators, as part of WHO’s annual round of global TB data collection. These show that progress in MAF-TB adaptation and implementation has been made in over 100 countries. In 2023, 92 countries reported that they had multisectoral accountability and review mechanisms in place, including 21 of the 30 high TB burden countries (Table 1). A total of 68 countries reported that civil society and affected communities were represented in their multisectoral accountability and review mechanisms, including 20 of the 30 high TB burden countries. In the same year, the number of countries that reported publishing an annual TB report on progress towards national TB-related targets and commitments was 130, including 24 of the 30 high TB burden countries.

Table 1 Status of core elements of multisectoral accountability for WHO regions, globally and the 30 high TB burden countries, 2023

WHO regions, global total and high TB burden countries	Number of countries and areas	National multisectoral and multistakeholder accountability and review mechanism, under high-level leadership available	Engagement of civil society and affected communities in the multisectoral accountability and review mechanism	Annual national TB report publicly available
African Region	47	27 (57%)	23 (49%)	37 (79%)
Region of the Americas	45	15 (33%)	12 (27%)	20 (44%)
South-East Asia Region	11	8 (73%)	5 (45%)	9 (82%)
European Region	54	22 (41%)	14 (26%)	31 (57%)
Eastern Mediterranean Region	22	8 (36%)	4 (18%)	16 (73%)
Western Pacific Region	36	12 (33%)	10 (28%)	17 (47%)
Global total	215	92 (43%)	68 (32%)	130 (60%)
High TB burden countries	30	21 (70%)	20 (67%)	24 (80%)

In 2023, data were also collected to better understand the extent to which different sectors were engaged in the TB response. The findings suggest that the most widely engaged sector was education, but that there is considerable scope to increase engagement across this as well as other sectors (Fig. 2, Fig. 3).

Education was the most engaged sector, with 40% of countries globally reporting that this sector was engaged in advocacy, information sharing, education and communication in the TB response (Fig. 2). The defence sector (in 30% of countries globally) and justice sector (in 28% of countries globally) are mostly engaged in TB prevention and care, and the social development sector (in 27% of countries globally) is mostly engaged in patient support, including provision of economic, social or nutritional benefits.

Fig. 2 Global percentage of countries with ministries (beyond health) engaged in the TB response in 2023 based on data reported by national TB programmes, for three topic areas

Fig. 3 Percentage of countries with ministries (beyond health) engaged in the TB response in 2023 based on data reported by national TB programmes, disaggregated by WHO region and for the 30 high TB burden countries

Box 1: Public–private mix monitoring and data dashboards in priority countries for stronger accountability

In addition to engagement across multiple sectors, it is also necessary to engage all care providers in the TB response, including those in the private and informal sectors. These providers are often the first point of care for TB patients. Failure to engage with these providers can have negative consequences, including increased transmission, increased drug resistance, catastrophic costs for TB patients and their households, and incomplete monitoring and evaluation. Such consequences can arise form factors such as delayed diagnosis, inappropriate or incomplete treatment and out-of-pocket expenditures.

For more than two decades, WHO has supported countries to scale up the engagement of all care providers through public–private mix (PPM) approaches. In terms of PPM monitoring, countries have mainly focused on tracking notifications from private and unengaged public sector care providers rather than a broader scope of indicators across the patient pathway. Recently, WHO has led efforts to strengthen PPM monitoring and accountability through an initiative with the Bill & Melinda Gates Foundation. This aims to develop enhanced PPM data dashboards in seven priority countries: Bangladesh, India, Indonesia, Kenya, Nigeria, Pakistan and the Philippines.

To set up PPM data dashboards in countries, WHO has collaborated with its regional and country offices and partners to better understand the systems that are already in place, and to build consensus on key PPM indicators for reporting and use. A prototype of a PPM dashboard was created following a consultation with the seven countries in November 2022. The indicators in the PPM dashboard are aligned with WHO guidance on TB surveillance and with WHO benchmarks and indicators related to universal access to rapid TB diagnostic tests.

The indicators are grouped into four categories: provider coverage, surveillance, service coverage and treatment outcomes. Disaggregation of data by ownership and health facility level are both core components of the PPM dashboard, to better understand patient pathways. Such disaggregation will also provide information about differences among providers in access to services such as WHO-recommended rapid diagnostics (WRD). Over the past year, WHO has supported the seven countries to set up national PPM data dashboards.

An example of the results produced from use of the PPM dashboards in Indonesia is provided in Table 2.

Table 2 PPM data dashboard with core indicators – Indonesia

		Non-profit (e.g. faith-based organization)			For-profit (private)			Public
Indicator	National	Primary	Secondary or tertiary	Total	Primary	Secondary or tertiary	Total	Primary	Secondary or tertiary	Total
Outcome
Successfully treated (2021 cohort): numerator	338 738	747	18 574	19 321	1606	40 386	41 992	223 618	53 807	277 425
Successfully treated (2021 cohort): denominator	391 245	934	22 312	23 246	1988	50 600	52 588	247 260	68 151	315 411
Service coverage
Bacteriologically confirmed	355 881	629	15 599	16 228	3113	36 759	39 872	209 420	90 361	299 781
Initial access to a WRD	425 746	780	21 670	22 450	3359	50 764	54 123	218 229	130 944	349 173
Testing bacteriologically confirmed for drug resistance	322 244	618	14 325	14 943	2826	33 239	36 065	182 789	88 447	271 236
Initial WRD for PTB	415 336	760	20 856	21 616	3331	49 491	52 822	215 563	125 335	340 898
Treatment initiation	617 655	991	38 179	39 170	6033	104 068	110 101	345 251	123 133	468 384
Received programme drugs	585 365	807	33 437	34 244	3860	87 564	91 424	344 005	115 692	459 697
TB preventive treatment	15 922	0	42	42	5	101	106	15 487	287	15 774
Surveillance
Presumptive TB patients	3 614 436	3611	110 664	114 275	34 643	294 224	328 867	2 655 492	515 802	3 171 294
Notified TB patients (new or relapse TB)	708 658	1100	49 075	50 175	8075	137 576	145 651	309 267	203 565	512 832
Notified TB patients (PTB)	655 220	1066	43 094	44 160	7827	122 281	130 108	299 664	181 288	480 952
Provider coverage
Providers active	13 471	41	426	467	911	1113	2024	10 017	963	10 980
Total providers	34 144	159	521	680	19 079	1411	20 490	11 869	1105	12 974

PPM: public–private mix; PTB: pulmonary TB; WRD: WHO-recommended rapid diagnostic

References

Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. New York: United Nations; 2023 (https://www.un.org/pga/77/wp-content/uploads/sites/105/2023/09/TB-Final-Text.pdf).
Multisectoral accountability framework to accelerate progress to end tuberculosis by 2030. Geneva: World Health Organization; 2019 (https://iris.who.int/handle/10665/331934).
World Health Organization Director-General Flagship Initiative to #ENDTB 2023-2027 [website]. Geneva: World Health Organization; 2023 (https://www.who.int/publications/m/item/who-director-general-flagship-initiative-to-endtb).
Strengthening multisectoral accountability to end TB [website]. Geneva: World Health Organization; 2023 (https://www.who.int/activities/strengthening-multisectoral-accountability-to-end-tb).
Adaptation and implementation of the WHO multisectoral accountability framework to end TB: operational guidance. Geneva: World Health Organization; 2023 (https://www.who.int/publications/m/item/operational-guidance-adaptation-and-implementation-of-the-who-multisectoral-accountability-framework-to-end-tb).
Adaptation and implementation of WHO's multisectoral accountability framework to end TB (‎MAF-TB)‎: best practices. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/365806).
WHO Multisectoral accountability framework for TB (MAF-TB): baseline assessment checklist for country use in pursuing a national MAF-TB. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/who-multisectoral-accountability-framework-for-tb-(maf-tb)-baseline-assessment-checklist-for-country-use-in-pursuing-a-national-maf-tb).