24th March 2015 is World Tuberculosis Day, and an opportune time to review progress in global TB control. The World Health Organization’s (WHO) Global TB Report 2014, published in October 2014, estimated that 9 million people developed TB in 2013, and 1.5 million died [1]. These figures are higher (half a million more cases) than what was estimated for the previous year, presumably because of intensive efforts to improve data collection and reporting.

Three issues in the latest WHO report are worrisome and worth highlighting. First is the enormous number of lives that are lost because of TB, which, for most part, is a highly curable disease. It is incredible that TB continues to be the second biggest killer disease from a single infectious agent. The second fact is the estimate by WHO that nearly 3 million people with TB are still being ‘missed’ by healthcare systems every year, either because they are undiagnosed, or because they are diagnosed but not notified to the healthcare system. The third issue is the continuing burden of multidrug-resistant TB (MDR-TB) with an estimated 480,000 new cases in 2013. Increasing use of rapid molecular tests like Xpert MTB/RIF (Cepheid Inc, Sunnyvale, CA) has resulted in a tripling of MDR-TB cases being diagnosed [1]. With nearly 9 million Xpert MTB/RIF tests procured (by last quarter of 2014), it is highly likely that we will uncover more and more cases of MDR-TB [2].

Missing cases, high death rate, and drug-resistance all point to one critical underlying problem – that high burden countries are unable to guarantee an acceptable quality of TB care to all patients, regardless of whether they seek care in the public or the private sector [3,4]. If patients with classic TB symptoms are not being diagnosed, this suggests poor adherence to international standards for diagnosis [5]. If patients are developing MDR-TB, this suggests poor adherence to treatment standards, and suboptimal adherence monitoring [5]. If patients with TB are not being notified, this suggests lack of engagement of private and informal health sector providers who often see TB patients first.

WHO, the Stop TB Partnership, and key stakeholders are aware of these serious challenges, and have recently announced an ambitious End TB Strategy, which aims to end the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic expenses due to TB [6]. A strategy to end TB is very ambitious and definitely welcome, because it may inspire country governments to step up their level of ambition and invest more in TB control. Indeed, the Indian government recently announced an ambitious plan to eliminate TB by 2020, and has endorsed the goal of universal access to quality TB diagnosis and treatment for all patients [7].

The critical importance of ambition, activism and advocacy is easily illustrated by the successes in the area of HIV prevention and care. A similar level of ambition and advocacy for TB control is great to see. However, if countries do not put resources behind ambitious plans, then progress will be stymied. India’s expenditure on TB control, for example, continues to be low, and TB elimination by 2020 is inconceivable at the current level of investment [7]. In contrast to China which made major investments in TB control and successfully reduced the prevalence of TB by more than half in the past 10 years [8], India has a long way to go in scaling up its capacity to detect and treat MDR-TB, engage the massive private sector, improve quality of care in the private sector, and address critical social determinants such as malnutrition and poverty. All of these will require substantially higher budgets than what is currently available [7,9].

Globally, the funding gap in TB has been highlighted [1]. An estimated US$ 8 billion is needed each year for a full response to the global epidemic, but there is currently an annual shortfall of US$ 2 billion [1]. Similar gaps in TB research and development (R&D) expenditure have also been highlighted [10]. Without sustained investments in R&D, it is unlikely that we will have new tools such as new TB drug regimens and vaccines.

The Stop TB Partnership’s theme for World TB Day 2015 is “Reach, Treat, Cure Everyone.” Without adequate resources, no country can reach and cure everyone. Political leaders and policy makers need to understand that TB cannot be eliminated without investing more resources. However, in the long run, TB control will result in substantial cost savings, and bring significant economic and health benefits to any country.