How Germany’s strategy to end tuberculosis could be much more effective

Jasmin Behrends
Advocacy Officer for Global Health, Médecins Sans Frontières (MSF) Germany

Tuberculosis (TB) is regarded by some people as a disease of the past, and people in Germany may only know it from books, or in connection with the lung sanatoriums of the late 19th century. However, it is still one of the deadliest infectious diseases in the world, with 1.3 million people dying from TB in 2022 alone per the World Health Organization (WHO). Clearly, high death rates, as well as the spread of resistant forms of TB, are an acute problem today, particularly in low- and middle-income countries, where access to tests and treatment for TB are limited.

Despite the global community having set itself the goal of ending TB by 2035, this is not realistic. This is because, although there are existing tests and drugs that can successfully diagnose and treat TB, these lifesaving medical products are often not accessible to people with TB who need them.

High prices prevent diagnosis and treatment

MSF is the largest non-governmental provider of TB treatment in the world. As we care for our patients, we see every day what it means when people don’t have access to effective tests and treatments. For example, globally, only two out of three people with TB are ever diagnosed and receive treatment. In children under the age of 5, up to 60% of TB infections go undetected, and therefore untreated. As TB is contagious, leaving people undiagnosed and untreated may lead to further spread of the disease.

There are many reasons for the gaps in TB care. But one of the main reasons why care cannot be scaled up is the disproportionately high price of tests and drugs. And pharmaceutical corporations have yet to demonstrate if and how these prices can be justified, especially as the prices seem to be calculated primarily to maximise profits, and not in relation to the costs of research, development, and production.

Why this concerns Germany

For many years, the German government has supported measures to control TB worldwide. One pillar of this commitment is payments to the Global Fund, an organisation that helps low- and middle-income countries to buy tests and drugs, and to take additional measures to build more resilient health systems.

Germany is the world’s fourth-largest donor to the Global Fund and has contributed more than €4 billion since the fund was established in 2002, including €1.3 billion for the current funding period of 2023-2025. It is incomprehensible for Germany not to maximise the impact of this investment. After all, Germany’s money could help save many more lives if the prices of tests and drugs were reasonable.

The German government’s commitment to the Global Fund will continue to be indispensable for low- and middle-income countries in the future, but why is the German government satisfied with a mediocre impact when it could save many more lives with this investment?

Prices are a powerful lever

A development last year showed the immense impact that lower prices can have:

An important and widely used test for diagnosing TB is the GeneXpert test from the US-based corporation Cepheid, part of the Danaher investment group. This test is recommended by the WHO for the diagnosis of TB, and most low- and middle-income countries rely on it to accurately diagnose TB. We at MSF use the GeneXpert test to detect TB, in addition to other diseases like HIV or hepatitis, for the people in our care.

Prior to September 2023, the price of a GeneXpert TB test from Cepheid was US$9.98 per test and $14.90 for extensively drug-resistant TB. Last year, following pressure from the Time for $5 Campaign, a coalition of civil society organisations and activists worldwide including MSF, Cepheid reduced the price per TB test to $7.97. As a result, the Global Fund is now saving more than $30 million a year and can provide 3.6 million more TB tests each year.

But this is not nearly enough. GeneXpert tests for other diseases, such as extensively drug-resistant TB, HIV, and hepatitis, are still overpriced. In 2019, an analysis by MSF found that it costs Cepheid less than $5 to produce a GeneXpert test, but charges at least three times that price to low- and middle-income countries. And, in high-income countries such as Poland, prices can be as high as $100.

Some countries pay twice

Like many pharma-industry corporations, Cepheid received substantial public funding — at least $250 million — to develop the GeneXpert technology. However, the corporation refuses to make their production costs or the public investment in research and development (R&D) publicly available and keeps their prices out of reach.

As a result, some countries are paying twice: first through financially supporting the R&D of medical products, and then by paying inflated prices once these products are on the market, as seen in the case of GeneXpert procured through the Global Fund.

A fair balance between industry interests and health needs

The example of the GeneXpert tests illustrates why a policy framework is needed to ensure greater transparency from the outset, and thereby ensure that access for people in low- and middle-income countries is considered for all products. One way to achieve this is to make public funding for pharmaceutical corporations conditional on final products being affordable and transparently priced.

By applying such conditions, the German government could ensure that public funds are used for public health and not for private profit maximisation. This would also help ensure that the much-needed resources of the Global Fund are used as effectively as possible.

The keyword here, is “transparency”. To provide greater clarity on the pricing for the GeneXpert TB tests, Cepheid has agreed to an internationally accredited third-party assessment every year. This should clarify if the new, lower price of $7.97 for TB tests is reasonable, as Cepheid claims, or, if the $5 price we are asking for is possible, and therefore more reasonable (as our analysis has shown). But for the result to be truly reliable and understandable, the method for determining the production costs as well as the outcome of the third-party assessment must be made public. Otherwise, the endeavour will fail. Here, too, political stakeholders have the power to demand clarity from the corporation, and they must use it.

Policy frameworks can create a balance between the interests of corporations and the health needs of people whose lives depend on access to medical products, especially people in low- and middle-income countries. After all, access to medicines and tests should not be a luxury.

Originally published in German in Frankfurter Rundschau.