Evaluation of the 2016–2020 regional tuberculosis response framework, WHO Western Pacific Region

Abstract Objective To assess the implementation of the Regional framework for action on implementation of the End TB Strategy in the Western Pacific, 2016–2020 in countries and areas in the World Health Organization Western Pacific Region. Methods We used a mixed methods approach to assess the framework’s measurable and perceived impact. We conducted an analysis of national tuberculosis strategic plans, a cross-sectional survey of senior staff of tuberculosis programmes, key informant interviews and some country case studies. Findings Of the 37 countries and areas of the Western Pacific Region, 14 had a national tuberculosis strategic plan, including all countries and areas with a high incidence of tuberculosis. Most senior tuberculosis programme staff who responded to the survey (16/23) found the regional framework useful when developing their national targets and grant applications. Programmatic challenges identified included financing, human resources, public–private mix, active case finding, and paediatric and drug-resistant tuberculosis. Most of the 17 key informants thought that the regional framework’s categorization of actions (for all settings, for specific settings and for pre-elimination settings) was useful, but that the added value of the regional framework over other relevant documents was not obvious because of overlap in content. Conclusion The regional framework influenced national level tuberculosis control planning and implementation in a positive way. A future regional framework should provide a longer-term strategic horizon and specifically address emerging trends and persistent problems faced by countries or areas of the region.


Introduction
Tuberculosis remains a major public health concern in the World Health Organization (WHO) Western Pacific Region. 1 The region has a population of 1.9 billion people with 37 countries and areas, including many Pacific Island countries and areas. 2 The region accounts for nearly 20% of the global burden of tuberculosis with an estimated 1.8 million incident cases in 2019; 1.4 million (78%) of these cases were reported to national tuberculosis programmes. 1 In 1999, the WHO Regional Committee for the Western Pacific declared a tuberculosis crisis in the region and the regional office subsequently established the Stop TB Special Project (now called the End TB unit). 3,4 The End TB unit has developed three regional strategic plans since the year 2000. [5][6][7] The current Regional framework for action on implementation of the End TB Strategy in the Western Pacific, 2016-2020 was published in 2016, after extensive consultation with countries and areas, regional experts and international partners engaged in tuberculosis control. 8 The framework was approved at the Sixty-sixth Regional Committee for the Western Pacific in October 2015 (resolution WPR/RC66.R3), 9 after the World Health Assembly had approved the new End TB Strategy 10 (resolution WHA67.1) in May 2014. 11 The regional framework for action aimed to interpret the concepts of the End TB Strategy in the particular circumstances and contexts of the countries and areas of the Western Pacific Region. Implementation of the framework required: "quality, people-centred TB services for all patients and families, action to address the looming burden of drug-resistant TB, social and financial risk protection to address vulnerability, effective regulatory policies to support TB control efforts, and new tools and capacity for rapid adoption of new technologies". 8 The regional framework built on the same three pillars as the End TB Strategy: (i) integrated, patient-centred care and prevention; (ii) bold policies and supportive systems; and (iii) intensified research and innovation. The framework included 16 subtopics linked to proposed actions with defined regional targets and indicators. In view of the diversity of the region, a tiered approach was proposed with actions for all settings, specific settings and pre-elimination settings. 8 Given that the regional framework defined a strategic vision until 2020, it was timely to review progress in implementation. We therefore aimed to assess implementation of the regional framework, and this paper outlines the main findings of our evaluation.

Study design
We undertook a mixed methods evaluation to assess the implementation of the regional framework and progress towards its targets and indicators. We conducted the evaluation in collaboration with the End TB unit of the WHO Regional Office for the Western Pacific, WHO country offices, national tuberculosis programmes and other stakeholders. The main objectives of the evaluation were to: (i) assess progress against the targets and indicators defined in the regional

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Regional framework on tuberculosis, Western Pacific Kerri Viney et al.
framework; (ii) determine how the regional framework has been adopted at the country level; (iii) ascertain the perceived value of the regional framework in achieving its objectives; and (iv) describe country-level challenges and success stories, the influence of the regional framework and future challenges. For the first objective, our findings have been reported in a separate paper, 12 complementing regular epidemiological analyses. 13 For the second objective, we undertook a review of national tuberculosis strategic plans and other relevant documents, while for the third objective, we conducted a cross-sectional survey of senior tuberculosis programme staff. In addition, we arranged key informant interviews to gather the views of a range of relevant stakeholders on the value of the regional framework, including senior advisers from international donor and technical organizations, tuberculosis programme managers and senior tuberculosis consultants or programme staff in selected countries, which also informed the final objective. Together with data from the epidemiological analyses, information from these interviews formed the basis of country case studies.
We chose this comprehensive mixed methods approach to obtain multiple perspectives and critical real-life insights. We carried out the evaluation (including data collection/interviews) between July and December 2019.

Data collection and analyses
We developed several evaluation tools which included a data extraction guide for the policy review (objective ii, available in the data repository), 14 an online crosssectional survey for senior tuberculosis programme staff (objective iii, available in the data repository), 14 and an interview guide for in-depth key informant interviews (objectives iii and iv, available in the data repository). 14 We performed a descriptive analysis of the policy review and calculated numbers and proportions for the cross-sectional survey. We summarized the results from the key informant interviews as a narrative and identified key themes. We developed country case studies using a set template (available in the data repository). 14 We did not require ethical approval for this quality improvement exercise. Countries and areas voluntarily provide their data to the WHO Global TB Programme, as part of standard reporting practices.

National tuberculosis strategic plans
Only 14 of 37 countries and areas of the region had a national tuberculosis strategic plan (Table 1), including all seven priority countries that collectively represent about 95% of the region's tuberculosis burden, i.e. Cambodia, China, Lao People's Democratic Republic, Mongolia, Papua New Guinea, Philippines and Viet Nam. 9 Of the other 23 countries and areas, 14 had a national health or development plan that included tuberculosis, while eight had no national health plan that we could find. These eight were all small Pacific Island countries or areas with a low burden of tuberculosis. As well, one country had a tuberculosis guideline, but not a national tuberculosis strategic plan. The 14 countries or areas that had strategic plans accounted for 99.7% of the regional burden of tuberculosis. Table 1 gives a summary of all the strategic plans we reviewed. Of the six strategic plans that had the same 5-year time frame (2016-2020) as the regional framework (Australia, China, Kiribati, Malaysia, Mongolia and Vanuatu), four referred to either the regional framework or the (. . .continued) Regional framework on tuberculosis, Western Pacific Kerri Viney et al.
preceding strategy (Kiribati, Malaysia, Mongolia and Vanuatu). 5 Two strategic plans started in 2017 (Lao People's Democratic Republic and Philippines) with the Lao People's Democratic Republic strategic plan clearly guided by the regional framework. The Australian national tuberculosis strategic plan referenced other WHO documents such as the End TB Strategy 10 and the framework on elimination of tuberculosis in low-incidence countries. 15 The Chinese national tuberculosis strategic plan did not reference any WHO documents, although we only reviewed an abbreviated translated version of this plan; however, the Chinese national tuberculosis strategic plan does not usually reference international documents (personal communication, Zhongdan Chen, WHO China Country Office, May 2020). The national tuberculosis strate-gic plans of Cambodia, Fiji, Japan, Papua New Guinea and Viet Nam all predated the current regional framework, and referred to other WHO documents as well as the millennium development goals (MDGs) 17 or the sustainable development goals (SDGs). 16 The four countries that had national tuberculosis strategic plans that were clearly informed by the regional framework were Kiribati, Lao People's Democratic Republic, Malaysia and Mongolia ( Table 2). The specified indicators were generally well aligned with the regional framework, although the catastrophic costs indicator was not included in plans from Kiribati and Mongolia. Most of the proposed actions in the regional framework for all settings were reflected in these strategic plans, but we identified some gaps. For example, actions related to social protection, health in all poli-cies, surveillance and assessment of vital registration systems, and pharmacovigilance were missing from the Mongolian national tuberculosis strategic plan. Table 3 (available at: http:// www .who .int/ bulletin/ volumes/ 99/ 5/ 20 -268060), provides a summary of the main objectives, indicators and targets in the national tuberculosis strategic plans of the seven priority countries of the region. The strategic plans of Cambodia, China, Papua New Guinea, Philippines and Viet Nam were mostly aligned with the WHO End TB Strategy, 10 as well as other international documents and national or local reports. A summary of the China national strategic plan was translated into English and reviewed for this policy analysis. Therefore, additional detail might have been missed as the full version was not available in English. Table 2. Alignment of national tuberculosis strategic plans with the regional framework a

Country
General approach Alignment with indicators and/or targets Alignment with proposed actions for b

All settings Specific settings
Kiribati Aligned with the End TB Strategy, 10 the regional framework 8 and the global leprosy strategy. 19  Adapted from the regional framework, 8 End TB Strategy, 10 Global tuberculosis report 2016, 20 and the toolkit to develop a national strategic plan for tuberculosis prevention, care and control 21 Partly: 25% reduction in number of tuberculosis deaths compared with 2015; increase in incidence rate of tuberculosis to 100 per 100 000 population compared with 79 per 100 000 in 2015 through enhanced case detection; zero families affected by tuberculosis facing catastrophic costs Almost fully: very closely aligned with the regional framework including many of the activities adopted from the regional framework Mostly: addresses tuberculosis in migrants (12-14% of the total tuberculosis caseload). The other proposed actions for specific settings are not relevant to the context of Malaysia

Mongolia
Largely informed by an evaluation of the national tuberculosis strategic plan 2010-2015 although the regional framework was referenced Mostly: to decrease tuberculosis incidence by 4% and mortality by 30% by 2020 compared with 2014 Mostly: some actions are missing, notably those related to social protection, health in all policies, surveillance and assessment of vital registration system, and pharmacovigilance NA NA: not applicable; PATLAB: Pacific TB Laboratory Network. a Regional framework for action on implementation of the End TB Strategy in the Western Pacific, 2016-2020. 8 b Elimination setting was not relevant to any of the four countries. c The private sector in Kiribati is small and may have been excluded for this reason. Note: "Fully" means that the indicators in the national tuberculosis strategic plan were the same three indicators in the regional framework with the same targets. "Mostly" means that some of the indicators were the same (not all three but that there was broad alignment). "Partly" means that fewer indicators were the same (usually only one or two, with less alignment with the regional indicators overall).

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Regional framework on tuberculosis, Western Pacific Kerri Viney et al.

Survey of senior staff
We received 23 of 37 completed surveys from senior staff members of national tuberculosis programmes and 19 respondents indicated that they had read the regional framework or part of it. Of these 19 respondents, 16 found the regional framework helpful in the development of their national tuberculosis strategic plan. Eleven of 22 respondents said that their national tuberculosis strategic plans were wholly or greatly guided by previous or current regional strategies.  28 and Towards tuberculosis elimination: an action framework for low-incidence countries. 15 Respondents indicated that the distinction between guidance for all, specific and pre-elimination settings was useful and ensured that the regional framework could serve as a resource for all countries and areas. Programmatic hurdles that the respondents thought needed to be considered when planning technical assistance or developing future regional frameworks included financing, human resources capacity, public-private partnership, active case finding, management of paediatric and drug-resistant tuberculosis and general health system challenges. Of 12 programmatic areas assessed, the senior tuberculosis staff thought that the regional framework provided the most relevant guidance on the treatment and care of adult tuberculosis patients, the development of adequate laboratory capacity to guide treatment of drug-resistant cases, and treatment and care of children with tuberculosis (Table 4).

Key informant interviews
We contacted 24 key informants for critical reflection on the value of the regional framework and we interviewed 17 of the informants contacted. Interviewees were with the main organizations and technical agencies working on tuberculosis control in the region and highlevel national tuberculosis programme representatives in certain countries (list of organizations and agencies available in the data repository). 14 Respondents thought that the regional framework had value, but considered that it duplicated the content of other WHO documents. Therefore, its added value compared with existing WHO documents required careful consideration. Interviewees had mixed responses on whether national tuberculosis programme targets were influenced by the regional framework. Specific examples where the targets differed included Viet Nam, which defined a prevalence (instead of incidence) target; Australia. which did not define a mortality target; and many countries which failed to include targets for cata-  (5) 1 (5) 3 (14) 11 (50) 6 (27)  22 3.91 Treatment and care for tuberculosis in children 0 (0) 1 (4) 8 (35) 10 (43) 4 (17)  23 3.74 Treatment and care for tuberculosis and comorbidities 1 (5) 1 (5) 6 (27) 11 (50) 3 (14)  22 3.64 Treatment and care for tuberculosis in high-risk populations 3 (13) 1 (4) 4 (17) 11 (48) 4 (17)  23 3.52 Strong laboratory networks to find all causes 1 (5) 1 (5) 5 (23) 11 (50)  Other areas 2 (15) 0(0) 6 (46) 5 (38) 0 (0) 13 3.08 a Regional framework for action on implementation of the End TB Strategy in the Western Pacific, 2016-2020. 8 b 1 = no positive influence to 5 = very strong positive influence. c A self-weighted average was calculated by the survey software (Survey Monkey®, San Mateo, United States of America). Note: Respondents were senior staff of national tuberculosis programmes.
Regional framework on tuberculosis, Western Pacific Kerri Viney et al.
strophic cost. Grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria are usually aligned with the targets in national tuberculosis strategic plans and therefore respondents felt that the regional framework had an indirect influence on Global Fund grant programming through its influence on national tuberculosis strategic plans. Most interviewees thought that providing particular actions for all settings, specific settings and pre-elimination settings was useful, but some actions were seen to be more achievable than others. Selected quotes about the perceived value of the regional framework and the relevance of proposed actions are included in the data repository. 14 To inform the development of a future regional framework or a similar strategic planning document, interviewees were asked about successes and challenges since the regional framework was released (Box 1). Generally, interviewees thought that a revised regional framework, and the necessary accompanying effort to launch and promote a framework, would help to keep tuberculosis on political agendas across the region.

Country case studies
Countries included in the case studies were Australia, Cambodia, China, Papua New Guinea, Philippines, Solomon Islands and Viet Nam. The focus of the cases studies was on key lessons learnt. Tuberculosis control in Papua New Guinea and the Philippines was facing significant challenges such as rising numbers of cases of multidrug-resistant tuberculosis and cases in children, while achievements such as productive research collaborations and a new social protection scheme were noted in Viet Nam. Fig. 1 shows the estimated incidence of tuberculosis and actual notified tuberculosis cases in the Philippines and Viet Nam from 2000 to 2018. The Philippines has one of the highest rates of tuberculosis (estimated tuberculosis incidence 554/100 000 population in

Box 1. Successes and challenges of national tuberculosis programmes mentioned by key informants, WHO Western Pacific Region
Detect Successes: strong focus on active case finding; general laboratory improvement and expanded networks for drug-resistant tuberculosis diagnosis and treatment, including the use of Xpert Ultra®, line probe assay and whole genome sequencing; low number of multidrug-resistant tuberculosis cases among new cases Remaining challenges: maintenance of Xpert ® MTB/RIF equipment and subsequent loss of skills in smear microscopy; scaling up of detection and treatment of paediatric tuberculosis; low case finding and treatment success for drug-resistant tuberculosis; inadequacy of efforts to find missing cases

Treat
Successes: removal of the category two regimen; availability of child-friendly water-dispersible fixed-dose combination tablets; better patient support to reduce catastrophic costs; implementation of short-course regimens for management of MDR and rifampicin-resistant tuberculosis; access to bedaquiline and delamanid as required Remaining challenges: poor patient-centred care (still a paternalistic approach); scaling up of detection and treatment of drug-resistant tuberculosis with high loss to follow-up; high cost of some medicines for multidrug-resistant tuberculosis which are not included in national drug lists and low treatment success

Prevent
Successes: better awareness of tuberculosis prevention and new WHO guidelines on infection prevention and control Remaining challenges: screening, prevention and treatment of latent tuberculosis infection; lack of commitment to provide preventive therapy to household contacts in high-incidence settings, even to vulnerable children

Recording and reporting
Successes: on track to reach targets but much left to do; relatively low caseload of multidrug-resistant tuberculosis Remaining challenges: improvement in documentation to obtain funding; strengthening of surveillance and use of data for field-based research to provide scientific evidence for policy-making

Research and innovation
Successes: more and better quality research undertaken, e.g. inventory studies, patient cost surveys, new diagnostics Remaining challenges: strengthening of research capacity and securing funding

Partnerships and collaboration
Successes: improved collaboration and better partnerships, and community engagement; improved private sector and donor engagement; more collaboration with other groups on tuberculosis care (e.g. civil society, nongovernmental organizations) Remaining challenges: still insufficient engagement of the private and non-public sector; insufficient engagement of civil society in tackling tuberculosis; overwhelming of national programmes by international partners

Health systems
Successes: increased funding from government; health system improvements, e.g. decentralized care; more attention on universal health coverage Remaining challenges: difficulty in using funding; regulatory barriers, e.g. excessive bureaucracy; strengthening of health-care delivery system; better trained human resources; large funding gaps for national tuberculosis plans

WHO regional office
Successes: improved commitment and top-level engagement after the UN high-level meeting on tuberculosis in 2018 Remaining challenges: better cross-regional collaboration and harmonization between the WHO Western Pacific and South-East Asia regions; maintaining political advocacy at the top level following the UN high-level meeting MDR: multidrug-resistant; UN: United Nations; WHO: World Health Organization. Notes: Each success or challenge does not necessarily apply to all the countries and some refer to the region more broadly. Key informants were senior advisers from international donor and technical organizations, tuberculosis programme managers and senior tuberculosis consultants or programme staff in selected countries.

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Regional framework on tuberculosis, Western Pacific Kerri Viney et al. 29 and evidence of tuberculosis transmission, usually demonstrated by high rates of tuberculosis in children and, when available, whole genome sequencing. 30 The Philippines has intensified active case finding activities among high-risk groups and vulnerable populations and has scaled up molecular diagnostic tests in line with the End TB Strategy and the regional framework. Therefore, the case notification rate has risen in recent years (Fig. 1). However, these gains may be undermined by issues such as inadequate funding, potential transmission of tuberculosis in prisons and other settings where large numbers of people are gathered, and the recent adverse effect of coronavirus disease 2019 (COVID- 19). Viet Nam has shown substantial progress towards the targets of the End TB Strategy with high-level political commitment to tuberculosis control efforts, productive research collaborations and intensified social protection schemes. Aligned with the End TB Strategy and the regional framework, molecular diagnostic tests and new regimens for drug-resistant tuberculosis have also been rapidly scaled up. However, in both the Philippines and Viet Nam, considerable gaps remain between estimated incidence and diagnosis of tuberculosis, with smaller gaps between diagnosis and treatment ( Fig. 2 and Fig. 3). For multidrug-and rifampicin-resistant tuberculosis, the gaps between estimated incidence and diagnosis are also considerable and the Philippines reports a gap between cases diagnosed and those treated ( Fig. 4 and Fig. 5).

Discussion
The framework aimed to assist the translation of the End TB Strategy to the national and regional context in the WHO Western Pacific Region. As such, the framework outlined ambitious tuberculosis targets for the region aligned with the End TB Strategy 10 and the SDGs: 8 a 95% reduction in tuberculosis deaths, a 90% reduction in tuberculosis incidence and zero catastrophic costs for households affected by tuberculosis by 2035 compared with 2015. However, the Western Pacific Region is not on track to meet these targets, given that the estimated tuberculosis incidence and mortality rates have decreased by  Regional framework on tuberculosis, Western Pacific Kerri Viney et al.
only 3% and 10% respectively since 2015, whereas the regional framework targets for 2020 were a 20% reduction in tuberculosis incidence and 35% reduction in mortality. 8,10 In the Western Pacific Region, tuberculosis treatment coverage (case detection) for drugsusceptible tuberculosis is currently 78% (1.4/1.8 million), indicating that about 400 000 cases are untreated every year; the largest case detection gap is in children under 5 years. 29 In 2018, 72% (72 216/101 000) of the estimated incident cases of drug-resistant tuberculosis were missed. 29 The rise in drug-resistant tuberculosis, coupled with an ageing population, 31 widespread undernutrition 32 and increased co-morbidities such as diabetes 33 and smoking-related lung disease, 34 are important challenges to regional tuberculosis control efforts. Thus, achieving the milestones and targets of the regional framework will require urgent implementation of specific actions in line with the principles of the End TB Strategy and the regional framework. 10,28,35 The success of any global or regional tuberculosis strategy is based on its translation into national strategic plans and actual on-the-ground implementation. 21 National tuberculosis strategic plans were key documents in this evaluation as they define the vision, goal and objectives of tuberculosis control efforts in a country and are a key tool for resource mobilization. Our evaluation showed that all seven priority countries, five of which also have a high tuberculosis burden, have a national tuberculosis strategic plan. In general, the regional framework provided valuable guidance to countries and areas drafting their strategic plans, but the timing of its release and short time frame (many completed their national tuberculosis strategic plan before its release), inadequate marketing and perceived duplication of content with existing WHO documents may have limited its influence and positive impact.
Our analyses showed substantial gaps in case finding and access to treatment in all country case studies, especially for people with drug-resistant tuberculosis. The need for focused strategies to tackle tuberculosis in high-risk subpopulations was highlighted during key informant interviews. In 2018, WHO, the Stop TB Partnership and the Global Fund launched a joint initiative (FIND. TREAT. ALL. #ENDTB) to urgently scale up tuberculosis case find-ing. 36 This initiative aims to diagnose, treat and report 40 million people with tuberculosis between 2018 and 2022, including 3.5 million children and 1.5 million people with drug-resistant tuberculosis, in line with the targets set at the UN high-level meeting on tuberculosis. 36,37 Countries and areas of the Western Pacific Region are encouraged to join these efforts and take action to close these case detection gaps and promote access to care.
Responses from national tuberculosis programme managers and key informants highlighted several areas to consider in a future regional framework. Several technical and programmatic problems were highlighted including laboratory capacity, large-scale case finding for active tuberculosis, drugresistant tuberculosis care, scaling up of preventive therapy and a lack of national research capacity to address key research questions specific to the country context.  Health system challenges noted included the need for universal health coverage (UHC) and the integration of tuberculosis services into primary health care, especially for children, with adequate financing mechanisms in place. 35,38 A future regional framework will need to be aware of these programmatic areas while accommodating the varied needs of countries and areas within the region. A regional framework should also include recommendations on accountability at the national, regional and global levels, given that WHO has now developed a multisectoral accountability framework, 39 which was an outcome of the United Nations high-level meeting on tuberculosis in 2018. 40 However, since our evaluation was performed, the global COVID-19 pandemic 41 has had substantial implications on national disease control programmes, including national tuberculosis programmes, 42,43 and regaining the lost momentum will take time and effort. Of the seven priority countries of the Western Pacific Region, Papua New Guinea and the Philippines have the biggest challenge because of large numbers of undetected cases and health system inefficiencies. 29 Strong political leadership and highly functioning partnerships will be required to improve the tuberculosis situation in these countries. Some small Pacific Island countries (such as Kiribati, the Marshall Islands and Tuvalu) are hotspots for tuberculosis (high rates of tuberculosis and evidence of transmission), although absolute case numbers are small. 29 Given their geographical isolation and the absence of drug-resistant disease, these countries could potentially serve as positive models for tuberculosis elimination. Population-based approaches for active case finding developed in the Marshall Islands 44 and Viet Nam 45 could serve as a template for island-wide elimination strategies, potentially screening for both active tuberculosis disease and latent tuberculosis infection, along with other diseases that may benefit from a similar approach.
Our evaluation has some strengths and limitations. We used both quantitative and qualitative approaches and explored the perceptions of national tuberculosis programme managers and key informants. However, the scope of our evaluation was broad and captured mainly people's opinions: validation of findings was limited, except in some country case studies. Furthermore, we were unable to validate the specific effect of the regional framework on policies and activities. We also found some inconsistencies between the different components of the evaluation; for example, in the survey of national tuberculosis programme managers, most respondents said that their national tuberculosis strategic plan was influenced by the regional framework, but only four countries published new national tuberculosis strategic plans after the regional framework. Managers might have thought that the regional framework would have influenced their national tuberculosis strategic plans if it had been available at the time, or that it is influencing current plans in development. Determining the real effects of the regional frameworks and strategies is challenging given the large number of priorities, needs, strategies, documents, organizations and funders that influence disease control programming. Although the scope of our evaluation did not cover all aspects of policy development and implementation, preparation of the regional framework included comprehensive consultation with countries and areas, and the formation of a regional tuberculosis technical advisory group has provided a strong platform to develop, disseminate and monitor future regional frameworks.
Overall, the regional framework has had a positive influence on national tuberculosis programmes in the Western Pacific Region, where tuberculosis incidence and mortality are slowly declining. The findings of our evaluation will inform the development of a future regional framework. This framework will be aligned with the priorities of countries and areas, the Thirteenth general programme of work, 2019-2023 of WHO, and the document: For the future: delivering better health in the Western Pacific Region. 46,47 WHO's thirteenth General Programme of Work is structured around three interconnected priorities linked to tuberculosis care: achieving UHC; addressing health emergencies; and promoting healthier populations, with targets of reaching 1 billion people in each thematic area. 46 In line with the triple billion theme, the vision for the WHO Western Pacific Region is summarized in the report For the future: towards the healthiest and safest region. 48 The priority areas for the region are: health security and antimicrobial resistance; noncommunicable diseases and ageing; environment and living conditions; and reaching the unreached. 48 Tuberculosis is linked to all four of these priorities and the next regional framework should reflect these links, with careful consideration of how to minimize duplication and maximize added value. ■

Country Period General approach Main indicators and targets
Cambodia 2014-2020 Aligned with the End TB Strategy, 10 the MDGs 17 and, to a lesser extent, the 2011-2015 regional strategy on tuberculosis in the Western Pacific 5 Prevalence of bacteriologically positive tuberculosis reduced by 5% a year in people > 15 years; Tuberculosis mortality rate reduced by 5.5% a year in the general population; Tuberculosis incidence rate reduced by 4% a year in the general population China 2016-2020 Aligned with national strategic blueprints and the End TB Strategy 10 Nationwide incidence of pulmonary tuberculosis reduced to lower than 58/100 000 population; Tuberculosis incidence in regions with the highest prevalence of tuberculosis reduced by 20% compared with 2015 Lao People's Democratic Republic

2017-2020
Aligned with the End TB Strategy, 10 and the regional framework 8 Number of tuberculosis deaths reduced by 35% compared with 2015; Incidence of tuberculosis reduced to 146/100 000 population compared with 2015; Zero families affected by tuberculosis facing catastrophic costs due to tuberculosis Mongolia 2016-2020 Largely informed by an evaluation of the national tuberculosis strategic plan 2010-2015 24 although the regional framework 8  Estimated tuberculosis prevalence rate reduced from 541/100 000 population in 2012 to 339 000/100 000 population by 2020; Estimated tuberculosis mortality rate reduced from 54/100 000 population a year in 2012 to 30/100 000 population a year by 2020 Philippines 2017-2022 a Primarily based on the End TB Strategy, 10 and the SDGs 16 Number of tuberculosis deaths reduced by 50%, from 22 000 to 11 000; Tuberculosis incidence rate reduced by 23%, from 554/100 000 population to 427/100 000; Catastrophic costs to households affected by tuberculosis reduced from 35% to 0%; At least 90% of patients satisfied with the services of the DOTS facilities Viet Nam 2015-2020 Based on the End TB Strategy, 10 Regional Green Light Committee report and other national documents Tuberculosis prevalence rate in the community reduced to 131/100 000 population, from 218/100 000 in 2012; Tuberculosis mortality rate reduced to less than 10 deaths/100 000 population, from 20/100 000 in 2012; Incidence rate of multidrug-resistant tuberculosis kept at less than 5% of total new tuberculosis cases DOTS: directly observed treatment, short-course; MDGs: millennium development goals; SDGs: sustainable development goals; TB: tuberculosis. a In the Philippines, the period of the national tuberculosis strategic plan (i.e. 2017-2022) is aligned with the term of the current government