WHO’s multisectoral accountability framework to accelerate progress to end TB (MAF-TB): latest status of progress in adaptation and implementation at global, regional and country levels
Progress in combating tuberculosis (TB) cannot be achieved by the health system alone; it requires firm political commitment at the highest level, strong multisectoral collaboration (beyond health) and an effective accountability system. This is especially important in the current context, owing to the coronavirus (COVID-19) pandemic which, coupled with ongoing crises (e.g. armed conflict, increasing food insecurity, political and economic instability), has reversed years of progress made in the fight to end TB, and placed an even heavier burden on those affected.
Since 2019, countries have been supported in systematically adapting and implementing the multisectoral accountability framework to accelerate progress to end TB (MAF-TB) (1) by the World Health Organization (WHO) and partners. The framework is well aligned with the End TB Strategy (2) and the 2030 Agenda for Sustainable Development (3). It aims to support effective collaboration within and beyond health sectors and the accountability of governments and stakeholders at global, regional and country levels, to ramp up the response towards ending TB. The framework builds on the requests made in the political declaration of the United Nations (UN) high-level meeting on TB (4) and the UN Secretary-General’s 2020 progress report (5), which provide WHO with the mandate to lead, coordinate and support MAF-TB processes at global or regional and national or subnational levels, including as part of preparations for the second UN high-level meeting on TB. The 2023 meeting will be the second time that heads of state have come together to deliberate on the global TB response, informed by national reviews of progress undertaken by countries. WHO’s multisectoral and multistakeholder platform will be leveraged to support countries with their reviews and preparations for the second UN high-level meeting on TB, in collaboration with WHO’s Civil Society Task Force on TB (CSTF).
Global level
At the global level, WHO has been working closely with various partner organizations to build capacity, increase awareness and share best practices and experiences of multisectoral engagement and accountability. The collaborating organizations include UN agencies – for example, the International Labour Organization (ILO), International Organization for Migration (IOM), World Food Programme (WFP), UN Children’s Fund (UNICEF), Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), Stop TB Partnership and CSTF – and other civil society and community organizations. The collaboration forms part of WHO’s collaborative multisectoral and multistakeholder platform that will be leveraged in 2022–2023 to support preparations for the second UN high-level meeting on TB, in collaboration with the CSTF.
To support countries in MAF-TB operationalization, WHO has developed two documents, an operational guide and a compilation of best practices on MAF-TB adaptation and implementation. The operational guide provides practical advice on key approaches and interventions needed to establish the MAF-TB at national and local levels; for each suggested approach and intervention there are concrete country examples, best practices and case studies. The guide also aims to encourage political leaders, policy-makers within and beyond the health sector, civil society and affected communities, international partners and funders to join forces in efforts to end TB. The compilation of best practices includes case studies from all six WHO regions, and provides important insights into how regions and countries are progressing with MAF-TB implementation. It also highlights lessons learned from experiences at regional, national and subnational levels that could guide stakeholders in further scale-up of MAF-TB implementation. Excerpts from the compilation of best practices are presented in Box 1.
| Box 1 Advancing MAF-TB to address TB among refugees and other
populations in humanitarian settings and to strengthen private sector
engagement
TB prevention and care among refugees and other populations in humanitarian settings Refugees and other populations in humanitarian settings face substantial threats to health and survival, such as poverty, crowded living conditions, undernutrition and poor access to health services – all conditions in which TB transmission thrives. To address this, WHO, in collaboration with the UN High Commissioner for Refugees (UNHCR) and the United States (US) Centers for Disease Control and Prevention (CDC), developed an interagency field guide that provides an overview of key actions in preparing for, and delivering, effective TB prevention and care services (i.e. diagnosis, treatment and prevention) for refugees and other populations during humanitarian emergencies. The actions are designed to be fully integrated within emergency preparedness planning and responses. The guide focuses primarily on managerial and organizational aspects of TB interventions, and provides links to the most updated references for the clinical aspects. Since its launch, the guide has already been translated into Ukrainian and used as a tool to provide guidance to Ukraine and other countries hosting refugees and affected populations. WHO is working extensively with partners to ensure the continuity of essential TB services for all people with or at risk of TB within Ukraine and refugee-hosting countries. A special WHO information note with guidance on this issue has been developed and disseminated. | |
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| Field guide | Information note |
| Public–private mix (PPM) data dashboards
WHO has been advancing MAF-TB efforts to strengthen the engagement of the private sector and other public care providers not linked to national TB programmes (NTPs) through a new initiative with the Bill & Melinda Gates Foundation. The initiative promotes the development of enhanced PPM data dashboards in seven priority countries: Bangladesh, India, Indonesia, Kenya, Nigeria, Pakistan and the Philippines. The countries were selected because together they have a burden of about 62% of the missing people with TB and a significant share (>60%) of private health service providers. These dashboards will strengthen reporting from the private sector and the unengaged public sector to track performance and increase accountability, which in turn will help to improve TB prevention and care, to close gaps and reach global and national targets. WHO is working closely with all seven countries to scope the PPM context and monitoring systems, to facilitate implementation of this initiative. | |
WHO continues to advocate for scaling up the MAF-TB through different events and forums to keep a high-level spotlight on the multisectoral response to end TB; for example, through the 2022 WHO Strategic and Technical Advisory Group for Tuberculosis (STAG-TB) meeting, Global TB Symposium, 7th End TB Strategy Summit and WHO’s Technical Experts Network on TB (TB-TEN) meeting. Capacity development efforts to enable MAF-TB adaptation and implementation at country level have been undertaken through a series of virtual-orientation webinars, including in collaboration with partners such as the Global Fund and the Stop TB Partnership.
WHO has been facilitating information-sharing among Member States through the MAF-TB virtual network, which is hosted on WHO’s interactive platform, the End TB Forum (https://whoendtbforum.org/topics). That forum also provides an effective platform for members to share experiences and respond to queries.
National level
There has been notable progress in MAF-TB adaptation and implementation in countries from all WHO regions (Table 1). In particular, the number of countries that publish annual TB reports on progress towards national TB-related targets and commitments increased from 62% to 77% during the period 2020–2022, with all high TB burden countries reporting this to be in place (Fig. 1). In 2022, 63% of countries reported that they have multisectoral accountability and review mechanisms, compared with 40% in 2020; of the high TB burden countries, 70% reported having these mechanisms in 2022, compared with 53% in 2020 (Fig. 2). Also, in 2022, 45% of countries reported having representation of civil society and affected communities in their multisectoral accountability and review mechanisms – a 1.5-fold increase from 29% in 2020 (Fig. 3). About 40% of high TB burden countries and 32% of all countries globally reported in their baseline assessments that they had engaged other sectors (e.g. ministries of education, justice or corrections, labour, finance and social welfare). Countries have used various approaches to adapt MAF-TB; some noteworthy examples documented by WHO are presented in Box 2.
Table 1. Status of core elements of multisectoral accountability for 30 high TB burden countries, WHO regions and globally, July 2022
| High TB burden countries and WHO regions | Number of countries and territories | Annual national TB reports publicly available | National multisectoral accountability and review mechanism under high-level leadership available | Engagement of civil society and affected communities in the multisectoral accountability and review mechanism |
|---|---|---|---|---|
| High TB burden countries | 30 | 30 (100.0%) | 21 (70.0%) | 17 (56.7%) |
| African Region | 47 | 46 (97.9%) | 34 (72.3%) | 31 (66.0%) |
| Region of the Americas | 45 | 26 (57.8%) | 23 (51.1%) | 12 (26.7%) |
| South-East Asia Region | 11 | 10 (90.9%) | 10 (90.9%) | 10 (45.5%) |
| European Region | 54 | 35 (64.8%) | 28 (51.9%) | 19 (35.2%) |
| Eastern Mediterranean Region | 22 | 20 (90.9%) | 16 (72.7%) | 7 (63.6%) |
| Western Pacific Region | 36 | 29 (80.6%) | 24 (66.7%) | 17 (47.2%) |
| Total | 215 | 166 (77.2%) | 135 (62.8%) | 96 (44.7%) |
Fig. 1. Trends in the public availability of annual national TB reports from 2020 to 2022 (%) a
Fig. 2. Trends in the set-up or strengthening of national multisectoral and multistakeholder accountability and review mechanisms under high-level leadership, as available from 2020 to 2022 (%) a
Fig. 3. Reported trends in the engagement of civil society and affected communities in the multisectoral accountability and review mechanism from 2020 to 2022 (%) a
Box 2 Country examples on MAF-TB implementation |
Armenia: Multisectoral perspective to the development of the National Strategic Plan |
In November 2019, the Ministry of Health established a multisectoral national working group to develop the National Strategic Plan (NSP); the group comprised representatives from regulatory authorities and agencies, including the National Centre for Pulmonology (NCP), National Centre for AIDS Prevention, civil society and TB-affected community organizations, TB research centres, and the Global Fund Project Implementation Unit. To ensure inclusivity and transparency, many different stakeholders involved in the TB response in Armenia participated in a 2-day national consultation, including health and nonhealth government sectors, civil society, TB-affected communities, academics and international organizations. All ministries involved in the implementation of the NSP for 2021–2025 were consulted, including the Ministry of Justice, Ministry of Foreign Affairs, Ministry of Labor and Social Affairs, Ministry of Finance, State Educational Institutions, and the Ministry of Development and Investments. The NSP development process was led by the NCP, with overall coordination from the WHO Country Office and technical support from the WHO Regional Office for Europe. To strengthen the role and engagement of civil society and TB-affected communities, the TB European Coalition, in collaboration with the NCP and WHO, organized a national policy dialogue in October 2020 to discuss the NSP, and to define areas of interest for civil society’s and TB-affected communities’ involvement in the response. |
Brazil: Meaningful engagement of civil society and TB-affected communities in TB response |
Since 2012, Brazil’s National TB Caucus has worked towards improving parliament’s commitment to engage meaningfully with civil society participation. The country’s NTP supports and recognizes the contribution of civil society and TB activists. The Brazilian National Community Advisory Board on Tuberculosis Research, the Brazilian Social Mobilization in the Fight Against Tuberculosis and many other regional or local committees, organizations and groups are involved in activities in the fight against TB, including undertaking policy reviews. In 2020, a task force of the above-mentioned civil society groups assessed the impact of COVID-19 on TB and HIV/AIDS policies in Brazil, with the findings presented to the NTP and the broader community. In addition, the Brazilian Stop TB Partnership (Parceria Brasileira Contra a Tuberculose) brings together public and private partners and international bodies and programmes. The Brazilian Network of Committees against TB incorporates 13 local committees and is primarily focused on community-based activities and advocacy. |
China: National multisectoral coordination and review mechanisms |
Following the inclusion of TB as a disease under key prevention and control measures in the Healthy China Action Plan (2019–2030) and the subsequent development of the End TB Action Plan (2019–2022), an interministerial joint conference system was established to coordinate nationwide TB prevention and care work, provide guidance on accelerating TB efforts, develop policies, and collaborate to solve major TB problems and challenges. This is a multidepartmental collaborative working mechanism to coordinate the prevention and control of major diseases under the leadership of the State Council. The National Health Department is the commander-in-chief of the multisectoral system, and there is participation from multiple ministries and agencies who carry out their work according to their assigned responsibilities. The Joint Conference Office, located in the National Health Commission, monitors and reviews the work in progress and provides timely reports on the implementation of the work. |
India: Development of anational MAF-TB |
India has developed a national multisectoral action framework for TB; this strategic document makes a strong case for transforming India’s TB elimination efforts from a health sector struggle to a whole-of-society responsibility. The framework is a guide for policy-makers and a call to action for communities, civil society, the private sector, and other partners and stakeholders. The overarching goal is to strengthen the country’s capacity for a multisectoral response that facilitates TB elimination by 2025, with the key objective being to achieve policy convergence and adopt a health-in-all approach. The framework highlights the six key strategic areas for integrated action: integrated health care service delivery; TB-free workplaces; socioeconomic support for patients; awareness generation and infection control; corporate social responsibility and investment in TB; and targeted intervention for key affected populations. It defines the list of government ministries and other stakeholders, and the strategic scope of collaboration with each of them. Also, the framework acknowledges the importance of resources for defined strategic areas (e.g. financing, capacity-building, technical resources and research), and calls on partners and governments to mobilize resources for its implementation. |
Pakistan: MAF-TB implementation at district level |
WHO is supporting a 3-month pilot of the MAF-TB at the district level in Hafizabad, Punjab. The initiative is led by the Department of Health and district health management team. The piloting experiences and lessons learned will pave the way for country scale-up. District authorities in the pilot have exhibited leadership as well as ownership by engaging sectors such as education, social and population welfare, prisons, religious affairs, labour, mass communication and the private sector. This has contributed to an increase in case detection during the pilot. In 2019, the Dopasi Foundation and Stop TB Pakistan, supported by the Stop TB Partnership, engaged various people in Sindh – the provincial health minister, the speaker of the provincial assembly, legislators, and senior functionaries of social sectors (e.g. population welfare, women’s development, education planning, finance, labour, social welfare and social safety nets) – to highlight the importance of committing to TB elimination and to adapting the MAF-TB at district level. The MAF-TB was endorsed by development partners, academics and public health experts seeking a TB-free Sindh. The goal was for Badin to become a model district for combating TB in the country. Following the development of the plan, a 2-day workshop was held in Badin to launch the project and define specific roles for all sectors in supporting the goal of ending TB led by the deputy commissioner. |
South Africa: Development and implementation of the MAF-TB |
To drive the MAF-TB development process in South Africa, the MAF-TB reference group was formed. The NTP, South African AIDS Council and WHO identified the Department of Health, the Civil Society Forum, people living with HIV and the Private Sector Forum as key stakeholders to form part of the group. The reference group advised stakeholders on WHO's MAF-TB baseline assessment checklist (6) and the development process. To inform the development of South Africa’s national MAF-TB, a desktop review of global and national TB commitments made by the country was conducted, along with an assessment of the country’s progress on associated global and national targets. WHO’s MAF-TB checklist was used in tandem with questionnaires for stakeholder interviews. A total of 65 people from different sectors were interviewed, including relevant government departments, civil society, nongovernmental organizations, donors, development agencies, the private sector, affected communities, research institutions and TB ambassadors. Based on the outcomes of the consultative process and baseline assessment, the findings and recommended actions were compiled and included in South Africa’s national MAF-TB. The MAF-TB also includes a roadmap for strengthening multisectoral involvement and accountability in the TB response. The MAF-TB process expedited the establishment of a new multisectoral TB technical working group (TWG), which brings together different stakeholders for the TB response. The TWG will facilitate joint planning, implement recommendations from the MAF-TB and link various sectors to the NSP development process. |
References
Multisectoral accountability framework to accelerate progress to end tuberculosis by 2030. Geneva: World Health Organization; 2019 (https://apps.who.int/iris/handle/10665/331934)
The End TB Strategy. Geneva: World Health Organization; 2015 ( https://www.who.int/teams/global-tuberculosis-programme/the-end-tb-strategy).
Transforming our world: the 2030 Agenda for Sustainable Development. New York: United Nations General Assembly; 2015 ( https://sdgs.un.org/2030agenda).
Resolution 73/3: Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. New York: United Nations General Assembly; 2018 ( https://www.who.int/publications/m/item/political-declaration-of-the-un-general-assembly-high-level-meeting-on-the-fight-against-tuberculosis).
Report of the Secretary-General. Progress towards the achievement of global tuberculosis targets and implementation of the political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. 75th session. Item 132 of the provisional agenda. New York: United Nations General Assembly; 2020 ( https://undocs.org/en/A/75/236).
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).