Several of the 17 Sustainable Development Goals (SDG) deal with health issues. The third goal, health and wellbeing, aims to “ensure healthy lives and promote wellbeing for all at all ages” and is clearly related to the tenth goal, the reduction of inequalities, and other SDG ¹1. Sustainable Development Goals. Sustainable development knowledge platform. https://sustainabledevelopment.un.org/?menu=1300# (acessado em 02/Fev/2018).
https://sustainabledevelopment.un.org/?m... . The SDG agenda, which succeeds the Millennium Development Goals (MDG), proposes to leave no one behind. In terms of health, the most coherent and accessible proposal to achieve these goals is universal health care through a strong primary health care system ²2. Chan M. From primary health care to universal coverage - the "affordable dream". In: Chan M , editor. Ten years in public health 2007-2017. Geneva: World Health Organization; 2017. p. 5-12. .

There are many challenges for meeting the targets within the SDG. An example is tuberculosis (TB). TB still poses a huge global health threat, with some 10 million new cases per year. In 2016, 1.3 million people died of TB, and another 370 deaths occurred in people living with HIV/AIDS ³3. World Health Organization. Global tuberculosis report 2017. Geneva: World Health Organization ; 2017. . Among the global efforts to control the disease, TB was included in target 3.3 of SDG ³3. World Health Organization. Global tuberculosis report 2017. Geneva: World Health Organization ; 2017. . The challenge is to eliminate TB as an endemic through 90% reduction in mortality and 80% in incidence by 2030, in order to eliminate the disease by 2050. The World Health Organization (WHO) launched the End TB Strategy to support these targets, with the additional goal that no patient should need to bear the catastrophic costs and social repercussions of the disease ⁴4. World Health Organization. WHO End TB Strategy: global strategy and targets for tuberculosis prevention, care and control after 2015. http://www.who.int/tb/post2015_strategy/en/ (acessado em 02/Fev/2018).
http://www.who.int/tb/post2015_strategy/... . This concern reflects the view that TB maintains the most vulnerable populations in a vicious circle, a view that sustains target 3.8 of the SDG ¹1. Sustainable Development Goals. Sustainable development knowledge platform. https://sustainabledevelopment.un.org/?menu=1300# (acessado em 02/Fev/2018).
https://sustainabledevelopment.un.org/?m... , which deals with achieving universal health coverage, includes protection from financial risk, and complements TB control. To reach these targets, three lines of action are recommended for governments: patient-centered care and prevention integrated with other care, bold policies and strong health systems, and acceleration of research and innovation ⁴4. World Health Organization. WHO End TB Strategy: global strategy and targets for tuberculosis prevention, care and control after 2015. http://www.who.int/tb/post2015_strategy/en/ (acessado em 02/Fev/2018).
http://www.who.int/tb/post2015_strategy/... .

At the current rate of reduction, these targets will not be reached within the deadlines laid out in international agreements ⁵5. Dye C, Glaziou P, Floyd K, Raviglione M. Prospects for tuberculosis elimination. Annu Rev Public Health 2013; 34:271-86. . Different tools are needed, since TB has biological, clinical, and socioeconomic determinants, including coinfection with HIV, malnutrition, smoking, poverty, overcrowding, and insufficient access to health care ⁴4. World Health Organization. WHO End TB Strategy: global strategy and targets for tuberculosis prevention, care and control after 2015. http://www.who.int/tb/post2015_strategy/en/ (acessado em 02/Fev/2018).
http://www.who.int/tb/post2015_strategy/... .

In Brazil, many determinants of TB overlap in poor urban communities, making it increasingly unlikely to meet the targets. In these neighborhoods, TB incidence exceeds 300/100,000 inhabitants, compared to 32.4/100,000 inhabitants in the country as a whole ⁶6. Departamento de Vigilância das Doenças Transmissíveis, Secretaria de Vigilância em Saúde, Ministério da Saúde. Brasil livre da tuberculose: plano nacional pelo fim da tuberculose como problema de saúde pública. Brasília: Ministério da Saúde; 2017. . Another extremely vulnerable urban group is Brazil’s prison population, with 31 times higher odds of catching TB compared to the general population ⁷7. Bourdillon PM, Gonçalves CCM, Pelissari DM, Arakaki-Sanchez D, Ko AI, Croda J, et al. Increase in tuberculosis cases among prisoners, Brazil, 2009-20141. Emerg Infect Dis 2017; 23:496-9. . Such TB hotspots, which must be identified and controlled in order to reduce transmission ⁸8. Dowdy DW, Golub JE, Chaisson RE, Saraceni V. Heterogeneity in tuberculosis transmission and the role of geographic hotspots in propagating epidemics. Proc Natl Acad Sci U S A 2012; 109:9557-62. , reflect the country’s health inequalities and pose a special challenge for controlling the disease.

Such inequalities exist not only in the determinants and risk of catching TB, but also in the treatment outcomes. While the risk of catching TB is ten times higher in Manaus (Amazonas State) than in Brasília ⁶6. Departamento de Vigilância das Doenças Transmissíveis, Secretaria de Vigilância em Saúde, Ministério da Saúde. Brasil livre da tuberculose: plano nacional pelo fim da tuberculose como problema de saúde pública. Brasília: Ministério da Saúde; 2017. , the odds of therapeutic success are four times lower in poorer people ⁹9. Belo MTCT, Luiz RR, Teixeira EG, Hanson C, Trajman A. Tuberculosis treatment outcomes and socio-economic status: a prospective study in Duque de Caxias, Brazil. Int J Tuberc Lung Dis 2011; 15:978-81. . Thus, in order for the goals and targets to be reached in Brazil, it is not enough to maintain interventions at the current levels. The country must do more, which means investing the necessary funds. For example, recent evidence shows that coverage by the Family Health Strategy ¹⁰10. Durovni B, Saraceni V, Puppin MS, Tassinari W, Cruz OG, Cavalcante S, et al. The impact of the Brazilian Family Health Strategy and the conditional cash transfer on tuberculosis treatment outcomes in Rio de Janeiro: an individual-level analysis of secondary data. J Public Health (Oxf) 2017; 1-8. and the Brazil Income Transfer Program ¹¹11. Torrens AW, Rasella D, Boccia D, Maciel ELN, Nery JS, Olson ZD, et al. Effectiveness of a conditional cash transfer programme on TB cure rate: a retrospective cohort study in Brazil. Trans R Soc Trop Med Hyg 2016; 110:199-206. increase the odds of TB treatment success in poor people, illustrating the benefit of social protection strategies in relation to TB outcomes. Although the cost-effectiveness of these interventions has not been analyzed in Brazil, arguments for making the necessary budget investments are backed not only by the irrefutable importance for public health and the struggle to reduce inequalities: fighting TB is also good business, since one dollar invested in reducing TB mortality generates a return of 43 dollars ¹²12. The economics of optimism: the debate heats up about what goals the world should set itself for 2030. The Economist 2015; 22 jan. https://www.economist.com/news/finance-and-economics/21640361-debate-heats-up-about-what-goals-world-should-set-itself-2030.
https://www.economist.com/news/finance-a... .

In order to look to the future with optimism and increase the odds of Brazil achieving its own targets for TB ⁶6. Departamento de Vigilância das Doenças Transmissíveis, Secretaria de Vigilância em Saúde, Ministério da Saúde. Brasil livre da tuberculose: plano nacional pelo fim da tuberculose como problema de saúde pública. Brasília: Ministério da Saúde; 2017. , we need an analysis that includes both the country’s potentialities and the risks created by the recent financial crisis and new austerity policies.

Brazilian Unified National Health System (SUS), guaranteeing universal access to heath, and the coverage rates in primary care (62.6% in late 2016) (e-Gestor Atenção Básica. Cobertura da atenção básica. https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml, accessed on 06/Feb/2018) are certainly major advantages, especially when compared to other countries (both medium and low-income) with high TB burden. Likewise, since Brazil has a well-consolidated national health surveillance system, the country has historical series and the conditions to make the necessary adjustments and establish an efficient system for monitoring the targets.

From the point of view of biological determinants, new technologies with shorter and more effective low-cost treatments and new and more streamlined diagnostic tests are necessary. However, although new technologies are available in the SUS that could have a profound impact on TB control, their use is suboptimal. One well-known example is the rapid molecular test, implemented in 96 Brazilian municipalities in 2014. The test replaces diagnostic bacilloscopy, which had only 50% sensitivity in two sputum samples, with 90% sensitivity in a single sample, thereby increasing diagnostic confirmation in Brazil by 60% ¹³13. Durovni B, Saraceni V, van den Hof S, Trajman A, Cordeiro-Santos M, Cavalcante S, et al. Correction: impact of replacing smear microscopy with Xpert MTB/RIF for diagnosing tuberculosis in Brazil: a stepped-wedge cluster-randomized trial. PLoS Med 2015; 12:e1001928. . However, according to a report by the Brazilian Ministry of Health ¹⁴14. Secretaria de Vigilância em Saúde, Ministério da Saúde. Rede de teste rápido para tuberculose no Brasil: primeiro ano da implantação. Brasília: Ministério da Saúde ; 2015. , 265,000 cartridges were distributed in the first year, but only 146,393 were used.

Even more striking are the low levels of implementation of the recommendation to test contacts and treat latent TB, proposed by the National TB Control Program for adults and children since 2010 ¹⁵15. Ministério da Saúde. Programa Nacional de Controle da Tuberculose: manual de recomendações para o controle da tuberculose no Brasil. Brasília: Ministério da Saúde ; 2011. . In addition to finding up to 6% of TB cases among contacts ¹⁶16. Fox GJ, Nhung NV, Sy DN, Hoa NLP, Anh LTN, Anh NT, et al. Household-contact investigation for detection of tuberculosis in Vietnam. N Engl J Med 2018; 378:221-9. , testing these individuals provides the opportunity to detect and treat latent TB infection, which affects 1.7 billion people in the world ¹⁷17. Houben RMGJ, Dodd PJ. The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. PLoS Med 2016; 13:e1002152. . Treatment of latent TB is the public health measure with the greatest impact on TB incidence rates ⁵5. Dye C, Glaziou P, Floyd K, Raviglione M. Prospects for tuberculosis elimination. Annu Rev Public Health 2013; 34:271-86. . In Brazil, only a negligible share of individuals targeted for this intervention are properly treated ¹⁸18. Salame FM, Ferreira MD, Belo MT, Teixeira EG, Cordeiro-Santos M, Ximenes RA, et al. Knowledge about tuberculosis transmission and prevention and perceptions of health service utilization among index cases and contacts in Brazil: understanding losses in the latent tuberculosis cascade of care. PLoS One 2017; 12:e0184061. , despite the high efficacy of the treatment regimens currently recommended by the WHO.

The situation is even more dramatic for TB patients living with HIV. Despite abundant evidence that treatment of latent infection reduces mortality, treatment of latent TB is rarely prescribed ²⁰20. Akolo C, Adetifa I, Shepperd S, Volmink J. Treatment of latent tuberculosis infection in HIV infected persons. Cochrane Database Syst Rev 2010; (1):CD000171. . Considering that TB is the leading cause of death in persons with HIV, millions of lives could be saved by the preventive treatment, which is simple, well-tolerated, efficacious, and cost- effective ²⁰20. Akolo C, Adetifa I, Shepperd S, Volmink J. Treatment of latent tuberculosis infection in HIV infected persons. Cochrane Database Syst Rev 2010; (1):CD000171. . Without a sharp turnaround in this situation, it will be impossible to meet the proposed targets.

It is equally important to enhance case detection and initiate early treatment. In Brazil, a significant proportion of TB cases are still notified only after patients have already died from the disease ²¹21. Selig L. The study of tuberculosis-attributed deaths as a tool for disease control planning in Rio de Janeiro, Brazil. Int J Tuberc Lung Dis 2003; 7:855-9. , showing that much progress is still needed in access, case investigation, and diagnosis of the disease. The country still falls far short adequate detection rates, and the situation may get worse. European countries that experienced financial crises and implemented austerity measures that impacted their health systems saw their detection rates fall, resulting in increased risks and resurgence of the disease ²²22. Reeves A, Basu S, McKee M, Sandgren A, Stuckler D, Semenza JC. Tuberculosis control and economic recession: longitudinal study of data from 21 European countries, 1991-2012. Bull World Health Organ 2015; 93:369-79. .

It is also necessary to increasingly incorporate innovations that improve diagnostic tests and make treatments quicker and less toxic. The key to incorporating innovations in order to obtain the best results from the investment is to have a well-financed and universal health system, along with an adequate information system that serves as a platform for the new technologies to reach everyone that needs them and to be evaluated and to generate data for more research and development. Without a strong universal health system, no technological innovation can be efficient. Finally, social protection should not be limited to health coverage, although more studies on the health impact of conditional cash transfer programs are necessary ²³23. Andrade KVF, Nery JS, Souza RA, Pereira SM. Effects of social protection on tuberculosis treatment outcomes in low or middle-income and in high-burden countries: systematic review and meta-analysis. Cad Saúde Pública 2018; 34:e00153116. .

In general, Brazil has the objective conditions to honor its international commitments and to be a global leader in the field, but it must not overlook the price needed to pay today in order to avoid facing much higher bills in the not-too-distance future.

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