Mandate a Composite 'Cascade Coverage Index' Alongside Every Treatment-Success Metric
Description
The fix is not a new dataset -- WHO, national TB programs, and Global Fund grantees already collect every number needed to compute the real cure fraction (estimated incidence, notifications, treatment enrollment, and treatment success).
The fix is a reporting rule: any agency publishing a 'treatment success rate' for a disease with a defined incidence estimate must publish it alongside a mandatory companion figure, the Cascade Coverage Index (CCI) = (patients enrolled / estimated incident cases) x (treatment success rate among enrolled). For 2024 DR-TB, that's 42% x 71% = ~30%.
This is not a new indicator invented from scratch -- it's the same 'cascade of care' logic HIV programs adopted after the UNAIDS 90-90-90 framework proved that reporting each stage of a care cascade separately, rather than just the final outcome, changed where donor money flowed.
TB and other diseases with strong treated-outcome metrics but weak enrollment-outcome metrics have not adopted an equivalent standard.
Mechanism: (1) WHO's Global TB Programme adds CCI as a mandatory field in the next Global Tuberculosis Report data collection cycle, calculated automatically from data countries already submit -- no new survey burden.
(2) The fact sheet and country profile pages display CCI directly next to treatment success rate, not buried in a supplementary table, using the same visual weight.
(3) Global Fund and other major donors add CCI trend (not just success-rate trend) as a scored criterion in grant renewal reviews, so programs are rewarded for closing the enrollment gap, not just for improving outcomes among patients they were already reaching.
(4) The same template gets piloted in one additional disease area in year two -- cervical cancer screening-to-treatment cascades are a strong candidate given similarly fragmented reporting.
Why this is tractable and cheap: it requires no new data collection, no new field visits, and no new trial. It is a reporting-format change plus a scoring-weight change at existing review checkpoints. The hard part is entirely political -- someone has to want the less flattering number to be visible -- which is exactly why it needs to be a rule, not a recommendation.
Implementation Pathway
Specification and pilot calculation
Mandatory reporting integration
Donor scoring adoption and cross-disease pilot
Required Resources
Impact Overview
Overall net impact: +6.33
Net Score by Horizon
Benefits vs Harms Count
- Benefits
- Harms
Impact Analysis
Platform AI · Gemini 3 FlashOverall Net Impact
Combined analysis across all timeframes
Short-term
0-2 years
- Immediate exposure of the 'missing millions' gap in TB care through high-visibility side-by-side reporting
- Zero-cost implementation utilizing existing WHO and National TB Program data streams
- Shift in donor discourse from 'quality of service' to 'equity of access' during grant reviews
- Increased pressure on national programs to explain discrepancies between notification rates and estimated incidence
- Political pushback and potential data suppression from countries whose success rates plummet when adjusted for coverage
- Initial demoralization of frontline staff who see their reported success drop from 90% to 30% overnight
Mid-term
3-10 years
- Reallocation of Global Fund and USAID resources toward active case-finding and diagnostic infrastructure
- Standardization of reporting in fragmented fields like cervical cancer screening-to-treatment cascades
- Improved accuracy of national incidence estimates as countries invest in better prevalence surveys to refine their CCI denominator
- Market signaling to diagnostic manufacturers that there is demand for tools to reach the 'uncounted' population
- Risk of 'volume over quality' where programs prioritize enrolling easy-to-reach cases to boost the numerator while neglecting treatment completion
- Strain on fragile diagnostic systems as funding shifts rapidly from clinical care to outreach
Long-term
10+ years
- Significant reduction in community transmission cycles by closing the gap of undiagnosed infectious cases
- Institutionalization of accountability where 'Universal Health Coverage' is measured by actual reach rather than theoretical quality
- Normalization of the 'Cascade' logic across all NCD and infectious disease reporting globally
- Sustainable strengthening of community-based health systems designed for active surveillance rather than passive facility-based care
- Potential for metric gaming through over-diagnosis or 'ghost' enrollment if digital health tracking is not robust
- Persistence of the 'incidence estimate' as a point of contention, leading to political disputes over the denominator rather than focusing on patients
- Over-diagnosis and unnecessary treatment of sub-clinical cases as health workers feel pressured to increase enrollment numbers to meet CCI targets.
- A shift in funding that inadvertently weakens specialized tertiary care centers by diverting budgets to aggressive primary-level screening.
- Diplomatic tension between the WHO and member states who may threaten to withhold data if the 'less flattering' CCI metrics affect their international standing or tourism.
Discussion
Discussion (1)
Success rates are an epidemiological illusion as long as we allow programs to ignore the millions of cases that never make it into the notification system.