Financing DOTS expansion
There has been a big increase in NTP budgets and a big improvement in the funding available for TB control since 2002, with particularly large increases between 2003 and 2004. The total reported NTP budgets for the 22 HBCs in 2005 are US$ 741 million, of which US$ 622 million is available and US$ 119 million is a funding gap. The total estimated costs of TB control 32 are projected to be US$ 1.3 billion, of which US$ 1.2 billion is already available. With the exception of large additional government contributions in China, Indonesia and the Russian Federation, almost all of the extra funding for TB control since 2002 is from GFATM grants. The GFATM now plays a major role in the financing of TB control, contributing more than one third of the budget in several HBCs, and over half in a few.
As usual, the summary statistics conceal important variations among countries. Our analyses suggest that in 2005, the HBCs fall into four categories. In the first are four countries (India, Myanmar, the Philippines and Viet Nam) that have budgets consistent with reaching the 2005 targets, and which are likely to have minimal or no funding shortfall. India has continued to expand rapidly with fully-funded budgets over the period 2002–2004, which, in 2003, provided more than enough money for planned activities. The Indian Revised National TB Control Programme has also maintained a constant budget per patient treated during the rapid expansion of DOTS. In the second are four countries that are close to being in this group, but which need to make up funding shortfalls (China, Cambodia), or where it is unclear how many more cases will actually be detected and successfully treated as a result of the substantial additional funds now available (Bangladesh, Indonesia). China stands out as having developed much larger budgets for 2004 and 2005 compared with previous years, for mobilizing a substantial increase in domestic and external financing to fund these budgets and for being the first HBC to secure full disbursement of a two-year GFATM grant. In the third group are five countries that report no, or negligible, funding gaps for 2005, but whose plans are not sufficient to reach the targets for case detection (e.g. Ethiopia) or there are doubts about whether existing plans will ensure achievement of the treatment success target (e.g. South Africa). The nine countries in the final group need special attention because they report large funding gaps and, in addition, do not expect to treat enough patients to reach the case detection target (eight countries) and/or there are doubts about whether they can reach the treatment success target. Among these nine countries, Nigeria and Zimbabwe are the only low-income HBCs not to have secured GFATM funding to date. Pakistan’s funding shortfall is a consequence, in large part, of planning for accelerated DOTS expansion in 2005.
The funding gap of US$ 119 million identified by all NTPs for 2005 is higher than reported in 2003 and 2004, but may still be an underestimate. The budget gap is the difference between the funds needed to carry out planned activities and the funds actually available. If the activities planned by NTPs for 2005 are a realistic assessment of what can achieved, the budget gaps reported are arguably an accurate reflection of the funding gap. However, the activities required to meet the 2005 case detection target are greater than planned in 12 countries, and while Brazil and South Africa may already detect more than 70% of all TB cases it is unclear whether they are budgeting sufficient resources to reach the target for treatment success. In this sense, the funding gaps are underestimates, although Brazil and South Africa are relatively wealthy middle-income countries that should be able to find any necessary resources from domestic budgets (Brazil has already increased its NTP budget by 50% since 2002). Apart from the question of whether NTPs are budgeting enough to meet targets, further reasons why the NTP budgets and associated funding gaps could be considered too low are the generally limited budgets for collaborative TB/HIV activities, especially in African countries, and the typically small or non-existent budgets for second-line drugs to treat MDR-TB patients (the Russian Federation is a notable exception).
For NTPs to carry out their activities as planned, they must actually receive the funds promised or anticipated. The establishment of the GFATM has not so far caused a decline in grant funding from other sources, and the Fund is thus apparently providing additional money. Nevertheless, its central financing role in several countries, and its smaller but nonetheless important contribution in others, means that the rate at which funds are made available in countries is of considerable importance. If these funds are not received by the NTP, gaps will replace expected GFATM contributions. This is a concern for some countries, where delays in receiving expected disbursements are already evident. The most important example is Mozambique, which had not received funds by the end of 2004, even though its proposal was approved in January 2003. Removing the obstacles to disbursement should be a priority, particularly in countries where GFATM grants contribute a large share of planned budgets.
For those countries that have secured large additional grants or loans, the key question now is whether the NTP can spend the money effectively. In 2003, expenditures were lower than the funding available, and in that year the total amount of money available was much lower than in 2004 or 2005. The most obvious need is for additional staff, particularly those with general and financial management skills. This need has already been recognized in several countries, and additional funds have been sought through the ISAC initiative. For example, China’s ISAC proposal includes a budget to support the recruitment of new staff at provincial level. Bangladesh has also identified a need for additional staff at central level, following its successful application to the GFATM.
When countries succeed in mobilizing additional funds, the new money must be translated into better programme performance. For most countries it is too early to say whether or not this is happening, because the biggest budgetary and funding increases have mostly been in 2004. However, it is striking that India’s TB control programme is both relatively low cost and very effective. As data become available for more years, it will be possible to assess the relative cost-effectiveness of TB control in the 22 HBCs, and the reasons for variation among countries.
Some HBCs still have difficulties in providing financial data. South Africa has not yet been able to complete the financial section of the WHO data collection form. A major part of the explanation is that budgeting for TB control is decentralized in South Africa. Decentralization has also affected the completeness of data available for Afghanistan and Thailand. Most NTPs find it more difficult to provide data on expenditures than budgets. Similarly, expenditures are not yet available on the GFATM web site, although the Fund does provide an impressive volume of data on budgets, grant agreements and disbursements. Efforts to follow up data were intensified in the African Region in 2004, and resulted in major improvements in the quantity and quality of data collected. Similar efforts are now needed in other regions, both for the HBCs and other countries.
In summary, financing for global TB control has improved since 2002, dramatically in some countries. Some HBCs now have sufficient funds, but must show that they can spend them effectively; some have no apparent shortfall, but should verify that their budgets are sufficient to meet targets; some have an obvious funding gap, and must focus on raising the money needed to improve programme performance.
32 i.e. NTP budgets plus the cost of hospitalization and outpatient clinic visits of TB patients that are usually not included in NTP budgets.