Financing DOTS expansion
Financial data were received from 134 out of 211 (64%) countries (Table 13), more in total than for 2004 (123 countries), but with fewer reports from the European Region. Complete budget data were provided by 70 countries (compared with 77 in 2004), and 69 provided complete expenditure data (down from 74 in 2004). Fewer complete reports were provided by the European Region and the Western Pacific Region, perhaps because more data were requested for the present report (in particular, two years of budget data rather than one). The main improvement in reporting was in the African Region, where the number of complete budget and expenditure forms increased by 37% and 44% respectively, probably because WHO regional office staff intensively followed up on data collection with NTPs.
Data were received from all 22 HBCs except South Africa (Table 14), providing the most complete set of data since financial monitoring was introduced by WHO in 2002. Complete budget data were provided for 19 countries (up from 17 in 2004); data were missing for South Africa and only partially complete for Afghanistan and Thailand. Complete expenditure data were provided for 17 countries (up from 15 in 2004); Kenya, South Africa and Uganda provided no data, and Afghanistan and Thailand provided incomplete data. A total of 20 countries made projections of the number of cases they would treat in 2004 and 2005, compared with the 16 countries that provided projections for 2004 in last year’s report. Again, the main improvement in reporting was in the African Region. Countries in the Western Pacific Region as well as India submitted, on time, exemplary data that required minimal follow-up.
Total NTP budgets and funding in HBCs
NTP budgets in 18 of the 22 HBCs have increased during the period 2002–2005, sometimes by substantial amounts (Figure 26, Figure 27, Table 15 columns 3 and 4). The total combined budgets for 2004 and 2005 are US$ 684 million and US$ 741 million, respectively, compared with around US$ 400 million in both 2002 and 2003. The main reason why the budgets for 2004 and 2005 are higher than in previous years is that countries are aiming to detect and treat more patients. This is associated with large proposed spending increases on initiatives to increase case detection and cure rates (US$ 160 million 2002–2005, of which US$ 39 million is in China), investment in buildings and equipment (US$ 63 million 2002–2005), and dedicated NTP staff (US$ 57 million 2002–2005). Important increases are also budgeted for first and second-line drugs (both up by about US$ 30 million 2002–2005). Relatively small budgets were reported for collaborative TB/HIV activities.
The countries with by far the largest budgets for 2005 (Table 15 column 2) are the Russian Federation (US$ 316 million) and China (US$ 158 million), followed by India and Indonesia (both around US$ 45 million). Other countries reported budgets of around or less than US$ 20 million. In absolute terms, China reported the largest budgetary increase between 2002 and 2005 (an additional US$ 60 million; Table 15, column 3). China is committed to achieving the 70% case detection target in 2005, and the budgetary increases reflect plans to achieve this.
The increase in the Russian Federation could be larger (US$ 178 million), if it is assumed that the 2002 budget was similar to reported expenditures (budget data were not reported for 2002). In 2003, the Russian Federation developed an ambitious five-year plan to expand DOTS and to upgrade TB control in general, covering the period 2003–2007. For other countries, the budget differences between 2002 and 2005 are all US$ 15 million or less.
In relative terms, the biggest budget increases are for Bangladesh and Pakistan (both more than 200%), followed by Kenya at 177% (Table 15, column 4). Six countries reported changes of 50–100% (Brazil, Cambodia, China, the Democratic Republic of the Congo, Myanmar, the United Republic of Tanzania), and four of 25–50% (Ethiopia, India, Indonesia, Nigeria). When compared with expenditures rather than budgets, the increases since 2003 are enormous for Zimbabwe (536%) and large for the Russian Federation (129%).
These large budget increases have been accompanied by big improvements in available funding for NTPs (Table 15 columns 5–8 and 10–13; Figure 27). For all HBCs, available funding has increased by about US$ 300 million since 2002, reaching US$ 622 million in 2005. In 2005, HBC governments will provide 62% of the required funding (including loans), the GFATM 15% and grants from other sources 7%, leaving a gap equivalent to 16% of the reported budgets. However, sources of funding vary among the 22 HBCs (Figure 28), with a few countries relying mostly on government funding but most relying extensively on grants from the GFATM and other sources. Most of the increased funding since 2002 is from governments (an increase of US$ 189 million since 2002, including loans, almost all of which is in China and the Russian Federation) and the GFATM (US$ 109 million for 17 HBCs in 2005 compared with no contribution in 2002). There has been virtually no change in grant funding from sources other than the GFATM.
Despite this progress in securing additional funding, there is a large funding gap of US$ 119 million in 2005 (Table 15 column 9), which is higher than the gaps reported for 2003 and 2004. In absolute terms, the largest funding gaps are those reported by China, India, Pakistan, the Russian Federation and Zimbabwe (US$ 93 million, or 78% of the total gap). The shortfall in India is associated with the end of the existing World Bank credit (1998–2004), but the balance is expected to be made up through additional grants and a new World Bank credit to be negotiated in 2005. Gaps in the other four countries are linked to the development in 2003 and/or 2004 of much more ambitious plans to expand and improve TB control. Proportionally, the largest gaps are in Kenya, Nigeria, Uganda and Zimbabwe (all more than 50% of the total NTP budget; Figure 28). These gaps are large enough to seriously constrain progress in TB control in these countries.
Further details, including charts showing trends in NTP budgets by funding source and line item for each year 2002–2005, are provided in the country profiles (Annex 1).
Total costs of TB control and funding in HBCs
NTP budgets include only part of the resources needed for TB control. In particular, they do not include the costs associated with general health services staff and infrastructure, which are used when TB patients are hospitalized or make outpatient clinic visits for directly observed treatment (DOT) and monitoring. For the 22 HBCs combined, the total costs of TB control are projected to be US$ 1.2 billion
The largest costs are for the Russian Federation and South Africa, which together account for US$ 700 million of the total cost of US$ 1.3 billion estimated for 2005. South Africa is a middle-income country, and the high costs are mainly explained by the higher prices for items such as hospitalization and outpatient visits, compared with those typical in low- income countries. The Russian Federation staffs and runs an extensive network of TB hospitals for treatment, has a large budget for second-line drugs to treat many MDR-TB patients and still carries out mass population screening by fluorography. China and India have the third and fourth highest costs, estimated at US$ 158 million and US$ 89 million respectively in 2005. Seven additional countries have total costs of US$ 25–50 million in 2005, three have costs of around US$ 20 million and the rest have costs of US$ 15 million or less.
The countries with the largest projected absolute increases in annual costs are the Russian Federation (US$ 154 million since 2003) and China (US$ 97 million since 2002). Increases of around US$ 20–30 million since 2002 are estimated for Bangladesh, India, Indonesia and Pakistan. The changes for other HBCs are around or below US$ 10 million. The biggest proportional increases are for Myanmar and Pakistan (both more than 200%), while increases are in the range 100–200% for seven additional countries.
Funding for the general health services staff and infrastructure used by TB patients during clinic visits and hospitalization is assumed to be funded by governments. This assumption, together with the implicit assumption that health systems have sufficient resources to support the treatment of growing numbers of patients in 2004 and 2005, means that the resources available for TB control are estimated to have increased from almost US$ 900 million in 2002 to US$ 1.2 billion in 2005 (Figure 30). The contribution by HBC governments to the total cost of TB control in 2005 is 79% on average, which is larger than their contribution to NTP budgets (Figure 31). This high average figure conceals important variation among countries; many HBCs are dependent on grants to cover more than one third of the total costs of TB control, or to close large funding gaps. The share of the total costs provided by HBC governments is closely related to average income levels (Figure 32), although Viet Nam stands out as a low-income country with a very high government contribution (90%).
For all HBCs, the estimated gap between the funding already available and the total cost of TB control is US$ 119 million in 2005, i.e. the NTP budget gap reported above. Further details, including charts that show trends in total TB control costs by line item for each year 2002–2005, are provided in the country profiles.
Per patient costs and budgets
There is much variation among countries in budgets and costs per patient (Table 17). The budgets for first-line drugs are lowest in India, Myanmar and the Philippines (US$ 11–17 per patient). In most countries, the budget is in the range US$ 20–35, but higher in Bangladesh, Brazil, Indonesia, Mozambique and the Russian Federation. Higher budgets in Bangladesh and Mozambique are explained by the creation of large buffer stocks, which distort the average value in 2005. In Indonesia, the drug budget has increased to allow use of fixed-dose combinations (FDCs).
The budget per patient, including all line items, is lowest in India, at US$ 34. The budget is also relatively low in Ethiopia and the Philippines (both around US$ 50) and in Myanmar (US$ 68). Most other countries (n = 13) have budgets in the range US$ 100–200 per patient. The only low-income country with a budget above US$ 200 per patient is Mozambique. The Russian Federation has by far the highest budget per patient, for reasons explained above (the figure for South Africa may also be high, but no data are available).
The total cost per patient treated in 2005 is lowest in India (US$ 66), below US$ 100 in Ethiopia and Myanmar, and below US$ 150 in Bangladesh and Uganda. It is in the range US$ 150–300 in 11 countries, 26 and slightly more than US$ 300 in three countries. There are three countries with much higher costs: Brazil, the Russian Federation and South Africa. Their higher costs are not surprising given their middle-income status and associated higher prices for inputs such as staff (Figure 33), as well as the extensive use of hospitalization in the Russian Federation.
Budgets and costs are generally stable (notably during a period of rapid DOTS expansion in India) or increasing.
Further details, including charts that show five per patient indicators (costs, budgets, available funding, expenditures and first-line drugs budget) for each year 2002–2005, are provided in the country profiles (Annex 1).
Expenditures in comparison with budgets and available funding
For countries that have received large increases in funding, the challenge now is to spend the extra money, and to translate extra spending into improved case detection and treatment success rates. The ability to spend available money can be assessed by comparing expenditures with available funding and budgets (Table 18). Complete sets of data on budgets, funds and expenditures are available for 15 HBCs in 2003 (the most recent year for which expenditure data are currently available). Expenditures were generally less than available funding. In India, costs proved to be lower than anticipated, and all planned activities were implemented. The capacity of the Tanzanian NTP to spend available money is discussed in Annex 1. For other countries, more work is needed to understand the reasons why expenditures are lower than available funding. The findings will have implications for programmes that are now benefiting from large influxes of new money. It is too early to say if large increases in spending can be translated into improved programme performance.
Budgets, funds and targets
Countries can be categorized according to whether the number of patients to be treated is consistent with meeting the 2005 targets, treatment success rates, the extent to which the budget for the projected number of patients is funded, how the budget per patient has changed through time and whether there is evidence that the additional funding can be effectively absorbed (Table 19). India, Myanmar, the Philippines and Viet Nam are in the best financial position to reach the targets (or to maintain the programme at target levels in the case of Viet Nam). Cambodia and China are well placed to do so if they can make up the remaining funding shortfalls. Indonesia appears to have the funding required to achieve targets, and Bangladesh may come close. However, it is unclear how many more cases will actually be detected and successfully treated as a result of the additional funds now available in these two countries. For the remaining 14 HBCs, the planned programmes of treatment are less than required to meet the targets for case detection (11 countries) and/or it is not clear if they are sufficient to meet the target for treatment success, although five of these countries report no or negligible shortfalls in funding.
GFATM contribution to TB control
High-burden countries. The GFATM is the single most important source of grant funding for HBCs, and several countries are relying on the GFATM to fund more than one third of their budgets. After four rounds of proposals, the total value of approved proposals (which, with four exceptions, cover five years) is US$ 818 million (Table 20). The amounts included in the two-year grant agreements 27 total US$ 218 million, and are sometimes lower than the amounts in years 1 and 2 of the original proposals (75% for those proposals for which both the original request for years 1 and 2 and the grant agreement amount are available; the biggest discrepancy is for Indonesia).
By the end of 2004, US$ 116 million had been disbursed. For each country, we can compare the actual and expected rates of disbursal, where the expected rate assumes that disbursements should be spread evenly over the two years following the date on which the agreement is signed (Table 20, column 7). China is the only country where all funds in the two-year grant agreement have been disbursed within the expected period of two years. For eight countries and 10 grants, disbursements are better than expected. 28 For five countries, disbursements are within 20% of the expected value, and for nine countries disbursements are around 25% or more below the expected value. One example is Ethiopia, a country that is largely dependent on GFATM funds. Another is Mozambique, which is also highly dependent on the GFATM, but which has to date received no funds at all, even though the grant agreement was signed in April 2004. The GFATM web site notes that initial disbursements are often small, given the need for strengthening programme capacity and preparation of procurement plans. 29 Furthermore, low disbursement rates appear to be associated with the principal recipient; for eight countries and nine grants where the disbursements are below the expected value, the GFATM web site notes that assessments of the principal recipient are pending.
The initial delay in disbursement is caused mainly by the time taken to sign the grant agreement after proposal approval. Once grant agreements are signed, disbursements are usually made within 2 months (the exception is currently Mozambique), compared with delays of between 5 and 23 (median value 11) months between grant approval and signature.
Other countries. After four rounds of proposals, 60 non-HBCs have approved proposals with a total value of US$ 400 million. The amounts included in the two-year grant agreements 30 total US$ 153 million, of which US$ 65 million had been disbursed by the end of 2004. Disbursements are generally similar or higher than expected values, except in the European and South-East Asia Regions. A summary table with the same indicators as those shown for the HBCs is available upon request.
The regional distribution of GFATM grants for HBCs and other countries is shown in Figure 34.
NTP budgets by WHO region, HBCs and other countries
NTP budgets and sources of funding by WHO region in 2005 are shown for both HBCs and non-HBCs in Figure 35, based on the 55 countries that submitted data of sufficient quality. Total budgets and sources of funding are dominated by the HBCs in the South-East Asia Region and the Western Pacific Region, because the HBCs account for almost all TB cases in these regions. While non-HBCs account for a large share of cases in the European Region, Eastern Mediterranean Region and Region of the Americas, we received insufficient data to make an assessment of total budgets and funding sources, or to make any useful comparisons between HBCs and non-HBCs. For the African Region, we had budget data for countries that account for 79% of TB cases. 31 Non-HBCs add substantially to the HBC budget totals (US$ 128 million versus US$ 77 million for HBCs alone). Proportional to budgets, funding gaps are smaller in non-HBCs in the African Region, with relatively higher funding contributions from the GFATM and governments.
26 This assumes that if data for Afghanistan were available, the cost would be in this range.
27 Signature of grant agreements is needed before any disbursements can take place.
28 However, the figure for Myanmar is misleading, because the NTP is a sub-recipient that had not received any funds by the end of 2004.
30 Signature of grant agreements is needed before any disbursements can take place.
31 If data for South Africa were available, the figure would be 89%.