VZCZCXRO4415
RR RUEHCHI RUEHDT RUEHHM RUEHLN RUEHMA RUEHNH RUEHPB RUEHPOD
DE RUEHGO #0279/01 1131038
ZNR UUUUU ZZH
R 221038Z APR 08
FM AMEMBASSY RANGOON
TO RUEHC/SECSTATE WASHDC 7415
RUCNASE/ASEAN MEMBER COLLECTIVE
RUEHZN/ENVIRONMENT SCIENCE COLLECTIVE
RUEHBJ/AMEMBASSY BEIJING 1817
RUEHBY/AMEMBASSY CANBERRA 1068
RUEHKA/AMEMBASSY DHAKA 4826
RUEHLO/AMEMBASSY LONDON 2015
RUEHNE/AMEMBASSY NEW DELHI 4616
RUEHUL/AMEMBASSY SEOUL 8156
RUEHTC/AMEMBASSY THE HAGUE 0669
RUEHKO/AMEMBASSY TOKYO 5717
RUEHRO/AMEMBASSY ROME 0153
RUEHFR/AMEMBASSY PARIS 0572
RUEHCN/AMCONSUL CHENGDU 1420
RUEHCHI/AMCONSUL CHIANG MAI 1510
RUEHCI/AMCONSUL KOLKATA 0278
RUEAUSA/DEPT OF HHS WASHDC
RHHMUNA/CDR USPACOM HONOLULU HI
RUEHPH/CDC ATLANTA GA
RUCLRFA/USDA WASHDC
RUEHRC/USDA FAS WASHDC
RHEHNSC/NSC WASHDC
RUCNDT/USMISSION USUN NEW YORK 1471
RUEKJCS/SECDEF WASHDC
RUEHBS/USEU BRUSSELS
RUEKJCS/JOINT STAFF WASHDC

UNCLAS SECTION 01 OF 04 RANGOON 000279 
 
SIPDIS 
 
SENSITIVE 
SIPDIS 
 
DEPT FOR EAP/EX; EAP/MLS; EAP/EP; EAP/PD 
DEPT FOR OES/STC/MGOLDBERG AND PBATES; OES/PCI/ASTEWART; 
OES/IHA/DSINGER AND NCOMELLA 
DEPT PASS TO USAID/ANE/CLEMENTS AND GH/CARROLL 
CDC ATLANTA FOR COGH SDOWELL and NCID/IB AMOEN 
USDA FOR OSEC AND APHIS 
USDA FOR FAS/DLP/HWETZEL AND FAS/ICD/LAIDIG 
USDA/FAS FOR FAA/YOUNG, MOLSTAD, ICD/PETTRIE, ROSENBLUM 
DOD FOR OSD/ISA/AP FOR LEW STERN 
PARIS FOR FAS/AG MINISTER COUNSELOR/OIE 
ROME FOR FAO 
BANGKOK FOR REO OFFICE, USAID/RDMA HEALTH OFFICE - JMACARTHUR, 
CBOWES 
TOKYO FOR HEALTH OFFICER 
PACOM FOR FPA 
 
E.O. 12958:N/A 
TAGS: ECON TBIO EAID SOCI PGOV AMED BM
SUBJECT: BURMA: LACK OF TB DRUGS A LOOMING PROBLEM 
 
REF: A) RANGOON 278   B) 07 RANGOON 1027   C) 07 RANGOON 1120 
 
RANGOON 00000279  001.2 OF 004 
 
 
¶1.  (SBU)  Summary.  Burma is one of 22 tuberculosis high-burden 
countries in the world.  The Government's National TB Program (NTP), 
 active in all of Burma's 324 townships, reported a case detection 
rate of 95 percent of all infectious cases and had a treatment rate 
of 83.6 percent in 2006.  The backbone of Burma's NTP is the 
availability of free first line drugs for 150,000 cases, provided 
free of charge from the Global Drug Facility (GDF).  However, GDF's 
commitment for free drugs will end in 2009, leaving Burma with no 
drugs to combat the second deadliest disease in the country.  The 
lack of TB drugs poses a huge challenge for TB infection control in 
Burma, and health experts predict that TB incidence rates, including 
multi-drug resistant and extremely drug resistant TB, will increase 
exponentially after 2009.  The GOB is considering applying for Round 
9 Global Fund assistance for 2011, but even if the Global Fund 
commits to providing TB drugs to Burma, there will still be a 
two-year gap in drug availability.  The Japanese Government is 
considering filling this gap, although has been reluctant to step in 
and provide drugs without an exit strategy.  End Summary. 
 
Current State of TB in Burma 
---------------------------- 
 
¶2.  (SBU)  Tuberculosis (TB) is a major public health concern in 
Burma and the WHO classifies Burma as one of 22 TB high-burden 
countries in the world.  While the true prevalence of TB in Burma 
remains unknown, the WHO estimates that more than 40 percent of 
Burma's population is infected with TB.  Some NGOs contend that up 
to 60 percent of the population could be infected (Ref B).  The 
Ministry of Health plans to conduct a National TB Prevalence study 
in 2008, although it lacks the $500,000 needed to do so.  Multiple 
drug resistant (MDR-TB) and extensively drug resistant (XDR-TB) TB 
rates are another concern - 2003 WHO studies proved that Burma had 
the highest rate of MDR-TB in Southeast Asia, with 4 percent of new 
cases and 15.5 percent of previously treated TB cases testing 
positive for MDR-TB.  The National TB Reference Lab in Rangoon is 
currently conducting a new drug resistance prevalence study. 
Results should be available in late 2008, although Dr. Ti Ti, 
Director of the National Reference Lab, predicted that the incidence 
rate of MDR-TB is likely to be substantially higher than 2003 
figures. 
 
Public-Private Partnership 
-------------------------- 
 
¶3.  (SBU)  Through its National TB Program (NTP), which is active in 
all 324 townships in Burma, the Burmese Government seeks to treat 
and prevent TB throughout the country.  The State and Division 
 
RANGOON 00000279  002.2 OF 004 
 
 
Health Departments are responsible for planning, coordination, 
training and technical support, and monitoring of health services on 
the state and division levels.  According to NTP Director Dr. Win 
Maung, township-level TB officers provide the actual health services 
to the people, including dispensing free TB drugs to patients and 
monitoring the patient's treatment.  In 2006, the NTP had a case 
detection rate of 95 percent of all infectious cases and a treatment 
rate of 83.6 percent in 2006, which exceeded WHO targets for 
combating TB.  Burma also has two TB hospitals, Aung San Hospital in 
Rangoon and Pathengyi Hospital in Mandalay, that provide treatment 
for the more challenging TB cases, including MDR and HIV/TB 
co-infection cases. 
 
¶4.  (SBU)  NTP activities are supplemented by services provided by 
private clinics, including those run by Population Services 
International (PSI), the Myanmar Medical Association, and Medecins 
Sans Frontieres-Holland (MSF-H).  PSI has clinics throughout the 
country, with 415 private doctors providing TB Directly Observed 
Short Course (DOTS) treatment in 100 townships.  MSF-H runs 24 
full-service medical facilities in six states and divisions, and MMA 
has 526 doctors providing DOTS treatment in 23 townships throughout 
the country.  Not all of these clinics provide the same services, 
although all will see and diagnosis TB patients.  PSI clinics treat 
TB patients directly, providing free TB drugs to patients, as well 
as conducting monitoring to ensure that patients complete the TB 
treatment protocol.  MMA clinics refer TB patients to local NTP 
clinics for treatment.  MSF-Holland also refers basic TB cases to 
the NTP, but will treat more difficult TB cases, specifically TB/HIV 
co-infection cases. 
 
¶5.  (SBU)  TB treatment in both the NTP and in private clinics 
follows the Directly Observed Treatment Short Course (DOTS).  Under 
the DOTS program, which was established with WHO assistance in 1994, 
a community or health care worker directly observes the patient 
swallowing their anti-TB medications over a six month period.  The 
NTP provides TB drugs (provided by Global Drug Facility) to both 
public and private clinics and requires that clinics keep detailed 
accounts of treatment for each patient.  Clinic doctors either 
monitor the patients directly or work with community volunteers and 
family members to ensure that the patients follow the treatment 
protocol. 
 
Securing Access to TB Drugs 
--------------------------- 
 
¶6. (SBU)  The backbone of Burma's TB program is the free drugs 
provided to TB patients.  The Global Drug Facility (GDF) currently 
is committed to providing first line TB drugs to Burma through the 
end of 2009.  The NTP each year receives DOTS protocol treatment for 
 
RANGOON 00000279  003.2 OF 004 
 
 
approximately 150,000 TB patients and distributes them through the 
NTP and PSI/MSF-H clinical sites.  The drugs are worth an estimated 
$4 million a year.  As the GDF commitment comes to an end, the 
Ministry of Health, WHO, and the private sector are scrambling to 
secure TB drugs for future years (Ref A).  The Burmese Government is 
unwilling to purchase these drugs directly, and the Ministry of 
Health, with its annual TB budget of $400,000 in FY2008, is unable 
to reallocate funding for first-line TB drugs. 
 
¶7.  (SBU)  Instead, the Ministry of Health is looking toward 
alternate providers of TB drugs, namely the Global Fund. 
Representatives from the Global Fund met with the Minister of Health 
in late March and encouraged him to submit a new application to the 
Global Fund, 3 Diseases Fund Manager Mikko Lainejoki told us.  While 
the senior generals are leery of the Global Fund after its abrupt 
departure from Burma in 2005, MOH officials told the 3D Fund and WHO 
representatives that the Burmese Government was considering 
submitting an application for Round 9, which would begin in 2011. 
However, even if the GOB secured a commitment from the Global Fund 
to cover first line TB drugs, there would still be a two-year gap in 
drug coverage.  This gap could create a dangerous situation in 
Burma, WHO Tuberculosis Officer Dr. Hans Kluge underscored.  The 
rate of TB infection would increase dramatically and people would be 
forced to buy inferior TB drugs on the local market.  If people do 
not complete the TB treatment and stop taking the drugs the minute 
they feel better, they could develop and spread MDR-TB, he stated. 
 
Filling the Gap 
--------------- 
 
¶8.  (SBU)  Recognizing the lack of TB drugs could pose both a 
domestic and regional problem, the Japanese Government is 
considering providing funds to cover the gap.  Masashi Ogawa, 
Economic Counselor at the Japanese Embassy, warned us that the 
Government of Japan support was not a forgone conclusion because 
relations between Japan and Burma cooled considerably after the 
shooting of the Japanese reporter in September.  The Japanese 
Government plans to reduce humanitarian assistance to Burma by 
one-third in 2008, so funding TB drugs may be politically 
challenging, he underscored.  If the Government of Japan agreed to 
provide TB drugs, it would only be for a few years, rather than long 
term.  Ideally, Japan would provide approximately $4 million in 
funding for 2010 after the Burmese Government agreed to apply for 
Round 9 of the Global Fund.  The last thing Japan wants is to start 
funding the program with no exit strategy, Ogawa stated. 
 
¶9.  (SBU)  During our two-week assessment of Burma's current TB 
situation, we found that most donors were confident that the 
Japanese would provide funding to cover the gap period, although 
 
RANGOON 00000279  004.2 OF 004 
 
 
they understood the political challenges facing the Japanese 
Government.  In the meantime, the WHO plans to encourage the GDF to 
extend its program an additional year, although Dr. Kluge told us 
that this was unlikely because the GDF had already extended its 
program in Burma by one year.  While some NGOs mentioned that the 3D 
Fund may shift resources to cover drugs, 3D Fund TB Officer Atila 
Molnar stressed that the 3D Fund did not have enough funds to cover 
the gap.  Additionally, the 3D Fund's mandate is to strengthen 
health care services at the township level; he doubted the 3D Fund 
Board would agree to divert resources from the local level to cover 
the cost of TB drugs.  There are only two options, Molnar declared: 
either the Japanese Government covers the gap period or the Burmese 
Government puts additional resources toward procuring drugs.  Since 
the second option is unlikely, he stated, donors will continue to 
pressure the Japanese to fill the gap. 
 
Comment 
------- 
 
¶10. (SBU)  During USAID's two-week assessment of Burma's TB program, 
we learned that the NTP faces many challenges in combating and 
preventing the spread of TB both inside and outside of Burma (Ref 
A).  However, officials from the Ministry of Health, NTP, 3D Fund, 
WHO, and NGOs all agreed that the most immediate challenge facing 
both the public and private sector is securing access to first-line 
TB drugs after 2009.  A solid first-line drug regimen is the 
backbone of Burma's TB program and is vital to preventing the spread 
of TB, including multi-drug and extensively drug resistant TB. 
Certainly, the Burmese military regime, with more than $2 billion in 
annual oil revenues, should be funding these, but it won't. 
Therefore, we should encourage the Japanese Government, the only 
donor who is able to procure drugs, to fund Burma's first-line TB 
regime for 2010 and beyond.  Once long-term access to drugs is 
secured, the NTP and the private sector can begin to address other 
challenges, including strengthening case detection and treatment, 
building capacity at the national labs, and improving infection 
control. 
 
VILLAROSA