Interview | ‘More investment will save millions more lives, accelerating the end of the TB epidemic’: Kunal Kishore, Chief of Party for Global Fund

"The Covid-19 pandemic has reversed years of progress made in the fight to end TB. In Nepal, anecdotal evidence suggests between 5-8 years of progress may have been reversed."

NL Today

  • Read Time 8 min.

Kunal Kishore currently leads the Global Fund Grant in Nepal as the Chief of Party and carries over 18 years of committed expertise in the development sector dedicated to the cause of marginalized communities, health, human rights, and civil society engagement. Before joining Save the Children as the Chief of Party for the Global Fund program, Kunal Kishore successfully led a Global Fund multi-country HIV grant in Asia, being implemented in Nepal, India, Thailand, Cambodia, Vietnam, Indonesia, and the Philippines. 

He has a proven track record of leading large-scale technical assistance programs at the country and regional levels. Through his work, he has impacted and touched countless lives at the local, national and international levels, especially in the South and Southeast Asian region. His passion and sound experience in policy advocacy, community-led campaigns, strategy development, design, and successful large-scale programs have helped shape robust national responses for key populations. He also has sound experience in providing financial and administrative oversight to establish effective and accurate project reporting, monitoring, and evaluation systems at multiple national and international organizations. He worked for the UN, government institutions, and civil society organizations.

His belief in people’s power and the cause of valuing each individual’s life, especially those at the margins of society, inspires him to relentlessly and persistently pursue and uphold his vision for the community. On the occasion of World TB Day, Nepal Live Today approached Kunal Kishore with questions to gain his insights.

To begin with, why is World TB Day relevant for Nepal? 

We commemorate World Tuberculosis (TB) Day each year on March 24 to raise public awareness about the devastating health, social and economic consequences of TB, and to step up efforts to end the global TB epidemic.

TB is contagious and airborne. It is one of the world’s deadliest infectious diseases. Every day, over 4,000 people around the world lose their lives to TB—a preventable and curable disease.

In Nepal, of the estimated 45,000 people who fell with TB in 2018, only 32,474 cases were reported. Around 12,000 cases are missed and are not reported to access quality care in our country. Additionally, drug-resistant TB continues to pose a dangerous health threat to our populations.

World TB Day marks the day in 1882 when Dr Robert Koch announced that he had discovered the bacterium that causes TB, which opened the way towards diagnosing and curing this disease. At the time of Koch’s announcement in Berlin, TB was raging through Europe and the Americas, causing the death of one out of every seven people. Koch’s discovery opened the way towards diagnosing and curing TB.

The theme this year is ‘Invest to End TB. Save Lives’. How is this theme relevant in Nepal’s context?

This year’s World TB Day is about putting all of these investments into a common goal: saving lives.  Every day in Nepal, around 20 people lose their lives to TB, and over 123 people fall ill with this preventable and curable disease. From the estimated 69, 000 people who fell ill with TB in 2018, only 32,474 cases were reported. Around 54 percent of cases were missed to be diagnosed and treated. It is in this context that the case for investing to end TB in Nepal as in the rest of the world—especially the global south—is first and foremost financial. Yet, the investment of hard work, determination, emotion, and energy are as essential as the monetary assets needed to end this preventable and curable disease.

It is said that the Covid-19 pandemic halted the progress in ending TB. Is that the case?

TB remains one of the world’s deadliest infectious killers. Each day, over 4100 people lose their lives to TB and close to 28,000 people fall ill with this preventable and curable disease. Global efforts to combat TB have saved an estimated 66 million lives since the year 2000. However, the Covid-19 pandemic has reversed years of progress made in the fight to end TB. In Nepal, anecdotal evidence suggests between 5-8 years of progress may have been reversed though this needs further study. For the first time in over a decade, TB deaths increased in 2020 world over.

“Every day in Nepal, around 20 people lose their lives to TB, and over 123 people fall ill with this preventable and curable disease.”

In this context, the theme ‘Invest to End TB. Save Lives’ conveys the urgent need to invest resources to ramp up the fight against TB and achieve the commitments to end TB made by global leaders. This is especially critical in the context of the Covid-19 pandemic that has put ‘end TB’ progress at risk, and to ensure equitable access to prevention and care in line with WHO’s drive towards achieving Universal Health Coverage. More investment will save millions more lives, accelerating the end of the TB epidemic.

WHO estimates that every day over 4,100 people die from TB, and nearly 30, 000 people fall ill despite it being a preventable and treatable disease. Despite huge investments from governments to prevent the disease, why is the number still high?

Given the impact of the Covid-19 pandemic achieving the annual investment target is especially important for Nepal and countries in its immediate neighborhood. WHO South East Asia estimates that in addition to the 10 percent increase in TB mortality in the region in 2020, case notification dropped from 3.6 million to 2.6 million—the same level as in 2015. In South East Asia alone achieving the region’s three billion US dollar annual investment target is especially important at a time when after five years of growth, the region suffered an economic contraction of -5.4 percent, pushing tens of millions of people into extreme poverty and exacerbating the social determinants of health.

Global Fund supports to implement programs for responding against TB, Malaria and HIV in Nepal. How is the organization working to combat the disease?

The Global Fund is a partnership designed to accelerate the end of AIDS, tuberculosis and malaria as epidemics. As an international organization, the Global Fund mobilizes and invests more than US $4 billion a year to support programs run by local experts in more than 100 countries including Nepal. In partnership with governments, civil society, technical agencies, the private sector and people affected by the diseases, Global Fund is challenging barriers and embracing innovation.

In Nepal, Save the Children is leading the implementation of the ‘Global Fund Strategy (2017-2022): Investing to End Epidemics’ which outlines Global Fund’s partnership’s bold agenda for the period 2017-2022 and is guided by the vision of a world free of the burden of AIDS, tuberculosis and malaria with better health for all. The Strategy has four strategic objectives at its core: a) Maximize impact against HIV, tuberculosis and malaria, b) Build Resilient and Sustainable Systems for Health, c) Promote and Protect Human Rights and Gender Equality, and d) Mobilize Increased Resources.

In doing so, health programs supported by the Global Fund partnership across the world have saved 44 million lives as of the end of 2020. Overall, the number of deaths caused by AIDS, TB and malaria each year has been reduced by 46 percent since 2002 in countries like Nepal where the Global Fund invests.

“Improving accountability, prioritization, engagement and investment for TB program at all levels is a major challenge in Nepal.”

In Nepal, currently, Global Fund is the largest funding partner and has committed approximately 82 million USD to end AIDS, TB and Malaria through the ongoing phase called New Funding Model 3 (or NFM 3). The period for this grant is from March 16, 2021 to June 2024.  

How many districts are covered by Global Fund’s programs related to tuberculosis prevention and treatment? What is the situation in Nepal in both rural and urban areas?

Save the Children through the Global Fund Program and in partnership with the NTC covers all of Nepal’s 77 districts and includes intensified strategies for 42 high burden districts. The map below explains the coverage of the 77 districts with an investment of over 20 million USD and combining strategies such as contact tracing, sputum courier, childhood TB, FAST, PPM, DR Hostel amongst others. 

How do Global Fund’s programs align with the government’s programs and priorities with regard to TB eradication?

Through Save the Children, Global Fund program in Nepal is supporting the National Tuberculosis Centre to achieve the ambitious goal of ending TB in Nepal by 2050 in accordance with the National Health Policy 2014 and under the strategic direction of the worldwide initiative to end TB—The End TB Strategy.   In this regard, Ending TB is defined as a decrease in the incidence rate of more than 80 percent by 2030 and 90 percent by 2035 compared to 2015 baseline. It is believed that a rapid expansion of the quality TB care services leading to increased access and effective implementation of the program through the responsible and integrated health system, intensified case finding and using appropriate preventive measures will help Nepal achieve the vision. More specifically, this is done through the following measures.

One, increasing case notification through sputum collection and transportation (SCT) mechanism in 42 districts, by household contact tracing and initiation of TB Preventive Treatment (TPT) among children below five in 42 districts, through Public Private Mix (PPM) in 7 metro and sub-metro cities and through TB screening among high risk and vulnerable populations in 10 prisons, nine border transits and malnourished children in 42 districts.

Other measures include conducting National Drugs Resistant Survey and Patient Cost survey, supporting to strengthen laboratory services, procurement of first and second-line TB drugs including shorter regimen, supporting DR treatment centers and strengthening national HMIS system and linking electronic case-based system of NTP with HMIS’s DHIS2 platform. Building capacity of provincial and local level staff through training, microplanning is another important measure.

What, in your opinion, are the prominent challenges of Nepal to decrease the incidents of TB?

There are a number of them. The first challenge is related to improving accountability, prioritization, engagement and investment for TB program at all levels. Enhancing the work efficiency of TB Focal Persons is another. Others include strengthening meaningful participation of the community and private sectors in TB diagnosis and treatment, expansion of newer technology and its maximum utilization for TB diagnosis, expansion and maximum utilization of sputum collection and transportation method, effective expansion of laboratories for TB diagnosis and its appropriate management and institutionalization and expansion of electronic case-based surveillance systems in both public and private sectors, and institutionalization of robust supervision system.

Challenges lie in the areas of increasing investment and effective implementation of TB infection control measures at all levels, implementation of TB program by integrating it with other national health programs related to HIV, IMNCI, tobacco control, diabetes, nutrition, women of reproductive age group, recently delivered women, pregnant women, infant and adolescents’ health etc. Besides, there is a lack of designated person to implement TB programs at local level. Hurdles remain in implementing TB program in a multi-sectoral approach to education, agriculture, finance, social security, employment, poverty reduction, etc. Challenge remains with regard to identifying patients diagnosed with TB but are unenrolled in TB treatment and bringing them in the continuum of TB treatment and care and Management of TB patients during pandemics like Covid-19 and ensuring the continuation of such services.

In your view, what are some of the remarkable jobs that Nepal has done to prevent TB incidents?

Actually, Nepal has taken a number of important measures in this regard. For one, DS TB is included in the package of basic health services and the patients with DRTB are covered by the national health insurance scheme. Likewise, the NTP has moved towards digitalized case-based surveillance. WHO-recommended mWRD has been expanded to 43 districts. Culture/DST laboratories have been established in two places. The services of transporting sputum to TB Diagnostic Centers and need-based referral system have been initiated. Similarly, work is underway to procure medicines for all forms of TB by the government of Nepal. TB Preventive Therapy for children below 5 years who have come in close contact with index TB patients has been started. Find Actively, Separating and Treating Effectively (FAST) approach has been launched to increase TB diagnosis among the service recipients at hospitals.

To appropriately manage TB among children after diagnosing it, the partnership has been established with Nepal Pediatric Association, professional authorities and other stakeholders. Furthermore, the capacities of doctors working in various parts of the country have been enhanced. As a result, the TB diagnosis rate among children has been increased. There has been an increment in the HIV testing rate among TB patients. Hospitals are being constructed for specialized treatment services for TB at the central level, and guidelines for the establishment and operation of TB treatment and referral management centers at the Provincial level have been implemented. Likewise, the treatment success rate of DS TB patients is 90 percent and the treatment success rate of drug-resistant TB patients is 70 percent. In addition, there has been a tremendous increment in the treatment success rate of DR TB with the introduction of the new and shorter regimens of TB treatment.

These are the very important measures which need to be further enhanced and continued.  On the occasion of World TB Day, I would like to say ‘Invest to End TB. Save Lives.’